HARDSHIP / RESTRICTED LICENSE APPLICATION

APPLICANT INFORMATION

Full Legal Name: _____________________________________________

Driver's License Number: _____________________________________________

State of Issuance: _____________________________________________

Date of Birth: _____________________________________________

Social Security Number (last 4): XXX-XX-_________

Current Address: _____________________________________________

City, State, ZIP: _____________________________________________

Phone Number: _____________________________________________

Email Address: _____________________________________________

SUSPENSION/REVOCATION INFORMATION

Date of Suspension/Revocation: _____________________________________________

Suspension/Revocation End Date: _____________________________________________

Suspension Order Number: _____________________________________________

Court Case Number (if applicable): _____________________________________________

Reason for Suspension (Check all that apply)

☐ DUI/DWI - First Offense
☐ DUI/DWI - Second Offense
☐ DUI/DWI - Third or Subsequent Offense
☐ Refusal to Submit to Chemical Test
☐ Point Accumulation/Habitual Offender
☐ Failure to Maintain Insurance
☐ Failure to Appear in Court
☐ Failure to Pay Fine
☐ Reckless Driving
☐ Drug-Related Offense
☐ Child Support Arrears
☐ Medical/Physical Condition
☐ Other: _____________________________________________

TYPE OF HARDSHIP LICENSE REQUESTED

☐ Restricted License (limited driving privileges)
☐ Occupational License
☐ Work Permit License
☐ Essential Needs License
☐ Business Purpose Only License
☐ Other: _____________________________________________

PURPOSES FOR WHICH DRIVING IS NEEDED

Employment (Check all that apply)

☐ Driving to and from place of employment
☐ Driving during the course of employment
☐ Driving for self-employment/business purposes
☐ Driving to seek employment

Primary Employer:

Company Name: _____________________________________________

Address: _____________________________________________

City, State, ZIP: _____________________________________________

Supervisor Name: _____________________________________________

Supervisor Phone: _____________________________________________

Work Schedule:

Distance from Home to Work: _____________ miles

Route (describe): _____________________________________________

Education (Check all that apply)

☐ Driving to and from school/college
☐ Driving children to and from school
☐ Driving for educational purposes

School Information:

School Name: _____________________________________________

Address: _____________________________________________

Class Schedule: _____________________________________________

Medical (Check all that apply)

☐ Driving to and from medical appointments
☐ Driving for ongoing medical treatment
☐ Driving family member to medical appointments
☐ Transporting family member requiring regular medical care

Medical Provider Information:

Provider Name: _____________________________________________

Address: _____________________________________________

Type of Treatment: _____________________________________________

Frequency of Visits: _____________________________________________

Court-Ordered Programs (Check all that apply)

☐ DUI/DWI education program
☐ Substance abuse treatment
☐ Community service
☐ Probation appointments
☐ Court appearances
☐ Other court-ordered obligations: _____________________________________________

Program Information:

Program Name: _____________________________________________

Address: _____________________________________________

Schedule: _____________________________________________

Family/Household Necessities (Check all that apply)

☐ Transporting children to school/daycare
☐ Grocery shopping/household errands
☐ Transporting family member to work
☐ Caring for elderly/disabled family member
☐ Religious services
☐ Other: _____________________________________________

LACK OF ALTERNATIVE TRANSPORTATION

I certify that I do not have reasonable alternative transportation available:

☐ No public transportation available in my area
☐ Public transportation schedule incompatible with my needs
☐ Distance to bus/train stop is too far
☐ No carpool options available
☐ Family/friends cannot provide regular transportation
☐ Ride-share services are not available or affordable
☐ Taxi service is not available or affordable
☐ Other: _____________________________________________

Explain why alternative transportation is not available:
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________

COMPLIANCE REQUIREMENTS

DUI/DWI Related Suspensions

☐ I have completed required DUI/DWI education program
Program Name: _____________________________________________
Completion Date: _____________________________________________

☐ I have enrolled in required substance abuse treatment
Provider: _____________________________________________
Start Date: _____________________________________________

☐ I have completed required hard suspension period
Hard Suspension Start: _____________________________________________
Hard Suspension End: _____________________________________________

☐ I have obtained required SR-22/FR-44 insurance
Insurance Company: _____________________________________________
Policy Number: _____________________________________________

☐ I have had Ignition Interlock Device installed (if required)
IID Provider: _____________________________________________
Installation Date: _____________________________________________

☐ I have paid required reinstatement fees
Amount Paid: $_____________________________________________
Date Paid: _____________________________________________

Point/Habitual Offender Suspensions

☐ I have completed required driver improvement course
☐ I have paid all outstanding fines
☐ I have resolved all pending traffic cases
☐ I have obtained required insurance

Insurance-Related Suspensions

☐ I have obtained valid insurance
☐ I have filed required SR-22/FR-44
☐ I have paid required fees

STATE-SPECIFIC REQUIREMENTS

CALIFORNIA

Hardship License Types:
- Restricted License (work/DUI program only)
- Critical Need Restriction

DUI First Offense:
- 30-day hard suspension required before restricted license
- Must show critical need for employment
- IID may be required in pilot counties
- SR-22 insurance required

Requirements:
- Complete DUI school enrollment
- File SR-22 insurance proof
- Pay $125 reissue fee
- Complete application at DMV

Form: Application for Restricted License

TEXAS

Hardship License Types:
- Occupational License (ODL)

Requirements:
- Petition to county/district court
- $125 application fee (plus court costs)
- SR-22 insurance required
- Cannot drive more than what court order allows
- Must carry certified court order while driving

Restrictions:
- Maximum 12 hours per day driving
- Essential needs only
- Specific routes/times may be specified
- IID required for DWI-related

Form: Petition for Occupational Driver's License

FLORIDA

Hardship License Types:
- Business Purpose Only License
- Employment Purpose Only License

DUI First Offense:
- Immediate hardship hearing available
- 10-day waiting period may apply
- Must complete DUI school enrollment
- Adjudication withheld may avoid hardship period

Requirements:
- Complete BPO/Employment Purposes Only application
- Provide proof of enrollment in DUI school
- Proof of employment (if employment purposes)
- Pay reinstatement fee

Form: Application for Hardship License (HSMV 72012)

NEW YORK

Hardship License Types:
- Conditional License
- Restricted Use License

Requirements:
- Complete Drinking Driver Program (DDP) enrollment
- Automatic conditional license upon DDP enrollment
- Pay $75 conditional license fee
- 20-day waiting period from suspension start

Restrictions:
- To and from work
- To and from school
- To and from DDP
- To and from court appearances
- Medical emergencies (household members)
- 3-hour block for household errands

Note: NYC residents with TVB-issued suspensions may have different rules

PROPOSED DRIVING RESTRICTIONS

I agree to the following restrictions on my driving privileges:

Time Restrictions

Allowed Driving Hours:
- Weekdays: _____________ AM/PM to _____________ AM/PM
- Weekends: _____________ AM/PM to _____________ AM/PM

Geographic Restrictions

☐ Within _____________ county only
☐ Within _____________ mile radius of home
☐ Specific routes only (describe): _____________________________________________

Purpose Restrictions

☐ Employment purposes only
☐ Medical purposes only
☐ School/education only
☐ Court-ordered program attendance only
☐ Essential household needs only (specific hours)
☐ Combination of above (as specified)

Vehicle Restrictions

☐ Personal vehicle only (non-commercial)
☐ Vehicle with IID installed only
☐ Specific vehicle only: _____________________________________________

SUPPORTING DOCUMENTATION ATTACHED

Employment

☐ Employer verification letter
☐ Work schedule documentation
☐ Pay stubs

Education

☐ School enrollment verification
☐ Class schedule

Medical

☐ Doctor's letter stating need for transportation
☐ Medical appointment schedule
☐ Treatment program documentation

Court-Ordered Programs

☐ DUI school enrollment certificate
☐ Substance abuse program documentation
☐ Probation officer letter
☐ Court orders

Compliance

☐ Proof of SR-22/FR-44 insurance filing
☐ DUI school completion certificate (if completed)
☐ IID installation verification (if required)
☐ Receipt for reinstatement fees paid
☐ Substance abuse evaluation

Other

☐ Proof of residence
☐ Vehicle registration (for IID vehicles)
☐ Statement explaining lack of alternative transportation
☐ Other: _____________________________________________

DECLARATION

I, [FULL LEGAL NAME], declare under penalty of perjury under the laws of the State of [STATE] that:

1. The information provided in this application is true, correct, and complete.
2. I understand that a hardship/restricted license is a privilege, not a right.
3. I agree to abide by all restrictions imposed on my driving privileges.
4. I understand that violating restrictions may result in revocation and additional penalties.
5. I will carry proof of my restricted license and any required documents while driving.
6. I will immediately notify the DMV/court of any changes in my circumstances.
7. I understand that driving outside my authorized restrictions is a criminal offense.
8. I will maintain all required insurance during the restricted license period.
9. I will not consume any alcohol or drugs before or while driving.

Signature: _____________________________________________

Printed Name: _____________________________________________

Date: _____________________________________________

EMPLOYER VERIFICATION (If Applicable)

To Be Completed by Employer:

I verify that [EMPLOYEE NAME] is currently employed by [COMPANY NAME] and that driving is necessary for:

☐ Commuting to and from work
☐ Performing job duties during work hours
☐ Both commuting and job duties

Employee's Work Schedule:
_____________________________________________

Is driving essential to this position? ☐ Yes ☐ No

Can alternative transportation be reasonably provided? ☐ Yes ☐ No

Employer Signature: _____________________________________________

Printed Name: _____________________________________________

Title: _____________________________________________

Company Name: _____________________________________________

Phone: _____________________________________________

Date: _____________________________________________

SUBMISSION CHECKLIST

☐ Application completed and signed
☐ All required supporting documents attached
☐ Filing fee included/paid
☐ SR-22/FR-44 on file with DMV
☐ Required waiting period has passed
☐ Court petition prepared (if required by state)
☐ Copies made for personal records

SUBMISSION INFORMATION

Submit to: [State DMV/Court Address]

Filing Fee: $_____________

Processing Time: Typically _____________ days

Questions: [State DMV Phone Number]

FOR OFFICIAL USE ONLY

This template is provided for general informational purposes. Hardship license eligibility, requirements, and procedures vary significantly by state and individual circumstances. Always verify current requirements with your state's DMV.