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Restricted Operators License Application Worksheet CCR O-24 - Virginia
| Restricted Operators License Application Worksheet Form. This is a Virginia form and can be used in Civil Circuit Court Fairfax Local County . |
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IN THE CIRCUIT COURT OF FAIRFAX COUNTY, VIRGINIA APPLICATION FOR RESTRICTED DRIVER'S LICENSE ................................................................ PETITIONER Case No. CL - . . . . . . . . . . . . . . - . . . . . . . . . . . . . . . .................................................. DRIVER'S LICENSE NUMBER STATE ................................................................ ADDRESS .................................................. DATE OF BIRTH HEIGHT WEIGHT ................................................................ CITY STATE ZIP .................................................. SEX EYE COLOR HAIR COLOR ................................................. PHONE NUMBER .................................................. DATE OF OFFENSE (IF APPLICABLE) .................................................. SOCIAL SECURITY NUMBER ADJUDGED AS A HABITUAL OFFENDER ON: . . . . . . . . . . . . . . . . . . . . . . . ADJUDGED TO BE A HABITUAL OFFENDER BY: DIVISION OF MOTOR VEHICLES CIRCUIT COURT THIRD OFFENSE RESTORATIONS: DIVISION OF MOTOR VEHICLES REVOKED OPERATORS LICENSE ON . . . . . . . . . . . . . . . . . . PURSUANT TO VIRGINIA CODE §46.2-391(B) .................................................. NAME OF PETITIONER OR ATTORNEY REPRESENTING PETITIONER . . . . . . . . . . . . . . . . . . . (Specify name of court) ................................................. PETITIONER OR ATTORNEY SIGNATURE .................................................. ATTORNEY ADDRESS (IF APPLICABLE) ................................................. ATTORNEY PHONE NUMBER (IF APPLICABLE) My driver's license has been suspended or denied but I am eligible for a restricted driver's license; therefore, I request that the court grant a restricted driver's license for travel to and from the following locations for the following purpose(s): (a) [ ] Travel to and from primary job Name and Address of Employer: . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............................................................................................................ (Court use only) APPROVED [ ] YES [ ] NO Days of Week: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Leave Home: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Arrive at Work: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Leave Work: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Arrive at Home: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VARIABLE SCHEDULE - WRITTEN VERIFICATION MUST BE CARRIED [ ] Travel to and from secondary job Name and Address of Employer: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............................................................................................................ Days of Week: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Leave Home: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Arrive at Work: . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Leave Work: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Arrive at Home: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] YES [ ] YES [ ] NO [ ] NO (b) (c) VARIABLE SCHEDULE - WRITTEN VERIFICATION MUST BE CARRIED [ ] Travel to and from VASAP [ ] Travel during work hours only as required by my employer: Hours of required travel: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] YES [ ] YES [ ] YES [ ] YES [ ] YES [ ] NO [ ] NO [ ] NO [ ] NO [ ] NO (d) VARIABLE SCHEDULE - WRITTEN VERIFICATION MUST BE CARRIED [ ] Travel to and from school Name and Address of school: . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Days of Week: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Leave Home: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Arrive at School: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Leave School: . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . Arrive at Home: . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SCHOOL SCHEDULE REQUIRED - WRITTEN VERIFICATION MUST BE CARRIED [ ] YES [ ] NO CCR-O-24 ROL Worksheet Civil Rev 7/1/2011 American LegalNet, Inc. www.FormsWorkFlow.com (e) [ ] Medically necessary travel for: me my elderly parent a person residing in my household . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] YES [ ] NO If for elderly parent or another person: Medical provider name: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........................................................................................................... (f) [ ] Ignition Interlock ] Necessary travel to transport a minor child(ren), who is/are under my care, to & from his/her/their school Name and Address of School: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Days and Times: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] YES [ ] YES [ ] NO [ ] NO (g-1)[ (g-2)[ ] Necessary travel to transport a minor child(ren), who is/are under my care, to & from day care Name and Address of Day Care Provider: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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