Request Of Driving Privileges

PORTAGE COUNTY COMMON PLEAS COURT DOMESTIC RELATIONS DIVISION 203 W MAIN ST., PO BOX 1035 RAVENNA OH 44266-1035 PHONE 330-297-3880 FAX 330-297-0190 REQUEST OF DRIVING PRIVILEGES **You must attach a copy of your driver's abstract from the registrar of motor vehicles** Case Number: Drivers License #: Yes CDL License NAME: ADDRESS: PHONE NUMBER: EMPLOYER: EMPLOYER'S TELEPHONE NUMBER: EMPLOYER'S ADDRESS: CITY: STATE: ZIP: SUPERVISOR'S NAME: BIRTHDATE: SSN: No DAYS AND HOURS YOU ARE SCHEDULED TO WORK (BE SPECIFIC): EDUCATIONAL/VOCATIONAL (NAME AND ADDRESS OF SCHOOL): CURRENT SCHOOL SCHEDULE IS ATTACHED MEDICAL: OTHER: INSURANCE COMPANY: POLICY NUMBER (ATTACH PROOF OF INSURANCE): INSURANCE AGENT: TELEPHONE NO: Yes No LIST ALL REASONS FOR WHICH YOUR DRIVER'S LICENSE IS CURRENTLY SUSPENDED: _______________________________________________________ SIGNED PRINTED NAME American LegalNet, Inc. www.FormsWorkFlow.com PROOF OF SERVICE I do hereby certify that a copy of the foregoing Request of Driving Privileges was sent by regular U.S. Mail to at and the Portage County Child Support Enforcement Agency, at 209 South Chestnut day of , 20 . Street, P.O. Box 1208, Ravenna, Ohio 44266 this _______________________________________ Signed NOTICE OF HEARING and the Portage County Child Support Enforcement Agency shall take notice that this matter shall come before the Court for hearing on the day, of 20 at A. M. ________________________________________ Signed X/Appendices[Index]/12 ­ Request Driving Privileges American LegalNet, Inc. www.FormsWorkFlow.com