Get OR DMV 735-6044 2007

DMV HARDSHIP / PROBATIONARY PERMIT APPLICATION Mail application and all requirements to DMV 1905 LANA AVE NE SALEM OR 97314 DEPARTMENT OF TRANSPORTATION DRIVER AND MOTOR VEHICLE SERVICES 1905 LANA AVE NE SALEM OREGON 97314 - NOT ISSUED FOR COMMERCIAL CDL DRIVING PRIVILEGES - SECTION 1 DRIVER INFORMATION DRIVER LICENSE / CUSTOMER NUMBER DATE OF BIRTH FULL LEGAL NAME Print last first middle CONTACT PHONE NUMBER RESIDENCE ADDRESS Address will be used to update your driver record/license MAILING ADDRESS IF DIFFERENT Address will be used to update your driver record/license No more than 12 hours of driving time allowed per day. You must sign your name at the bottom of this application* DRIVING FOR WORK Must also submit employment verification see reverse side . NAME OF EMPLOYER COMPANY ETC. Are you self-employed WORKSITE ADDRESS Circle work days YES NO EMPLOYER PHONE NUMBER MON TUE WED THU FRI SAT Mileage to work one-way SUN List Work Shifts specify am/pm Do NOT include drive times. DMV will determine and add driving time to your work shifts depending on mileage listed* Example If you note your work shift is 7am-3 30pm DMV will list your drive times as 6am-7am and 3 30pm-4 30pm* Do you drive on the job Do you drive employer s vehicle s If yes employer letter must verify you are required to drive on the job. List counties driven while on the job Counties must connect ALCOHOL and/or DRUG TREATMENT Driving time for treatment is separate from and not included in the 12-hour driving time limit* Use a separate piece of paper if necessary. NOTE Requests for several meetings may be denied due to limited space on the permit. Please note preferred meeting first. Name and address of meeting Circle meeting days Time meeting starts and ends am pm COURT RECOMMENDATION A recommendation from the convicting court is required if you are currently suspended for driving under the influence of intoxicants DUII eluding reckless driving or misrepresentation of age. NOTE The following are NOT convictions for DUII and do NOT require a court recommendation A Diversion Agreement granted by the court or a suspension for failing or refusing to submit to a breath test blood test urine test or a combination thereof under the Implied Consent Law. Judge s recommendation per ORS 807.250. APPROVED DENIED Judge s Comments COURT SIGNATURE OF CONVICTING JUDGE DATE X APPLICANT SIGNATURE By signing I affirm that the information given on this form is true and accurate and this form demonstrates my need to such a permit. I must notify DMV in writing if information on this application changes. The permit once issued constitutes my consent to abide continuously to all conditions requirement and restrictions while driving. 735-6044 1-15 STK 300224 DMV field offices cannot process the application* Hardship/probationary permits are subject to the fees provisions conditions prohibitions and penalties applicable to a license including Oregon residency and no suspensions in any other state. REQUIRMENTS FOR ALL HARDSHIP/PROBATIONARY PERMITS Application completed and signed Fees Application Fee .. 50 Non-refundable ORS 807.240 6 Reinstatement Fee .. .. 75 TOTAL 125 Check or money order SR22 Insurance Certificate Have an automobile insurance company file an Oregon SR-22 certificate with DMV. Must be the original SR22 no copies or faxes . DMV will not issue the permit until the SR22 becomes effective. Employment Verification If employed submit a letter from your employer verifying employment on company letterhead signed and dated listing days and hours of employment and stating need to drive on the job if required* If self-employed submit a copy of your current business license must show your name and business name a copy of your signed tax statement for the preceding year or two other documents such as a current customer signed business receipt advertisements signed contracts signed and dated letters from customers etc* ADDITIONAL REQUIREMENTS You may have additional requirements if you have been convicted of Driving Under the Influence of Intoxicants revoked as a Habitual Offender etc* Call DMV at 503 945-5000 to determine if any additional requirements are needed* Are you revoked for Habitual Offender If yes you must complete a Medical Diagnostic Exam* To meet the eligibility requirements for a Medical Diagnostic Exam your physician must complete and sign this medical statement. Do not send DMV a copy of the actual Medical Exam* If you are not able to obtain a doctor s signature on this medical statement call the Driver Safety Unit at 503 945-5083 to obtain a Driver Medical Report form for your doctor to complete. PATIENT S LAST NAME Please Print FIRST NAME MIDDLE NAME I have taken a medical history and completed a physical exam on the above named patient. In my opinion the patient does not have a physical or mental condition or impairment that affects the patient s ability to safely operate a motor vehicle. SPECIALTY MEDICAL PROVIDER NAME Please Print TELEPHONE NUMBER SIGNATURE OF MEDICAL PROVIDER DATE OF EXAM Month Day Year LICENSE OR CERTIFICATE FAX NUMBER DATE SIGNED Are you suspended ONLY for an uninsured accident or misrepresentation of age If yes you may be eligible for the following driving privileges medical appointments grocery shopping child care school and to care for elderly family members. Call DMV at 503 945-5000 to determine if you are eligible for additional driving privileges and to obtain a list of required information to submit with your request. WHAT S NEXT The Driver Suspension Unit will review your application and notify you of any additional requirements you must complete before a permit can be issued* If you have additional requirements and you do not comply with all requirements within 60 days your application will be denied and you will need to re-apply for the permit which includes submitting all new documents and 50 application fee. Once your application is approved and all requirements are met DMV will mail you a restriction letter. Take the restriction letter to a DMV field office to obtain a restricted driver license. Your driving privileges are not valid until you have obtained both the restriction letter mailed from Headquarters and a driver license with a J restriction code issued at a field office.