Fillable Printable Form 4595 - Application For Limited Driving Privilege

Form 4595 - Application For Limited Driving Privilege

Driver License Number Date of Birth (MM/DD/YYYY)

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Name (Last, First, Middle Initial) Social Security Number

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Street Address (Do not use P.O. Box) City, State, ZIP Code

Mailing Address (If different from street address) City, State, ZIP Code

E-mail Address Phone Number

If the application is approved, an order granting the limited driving privilege will be mailed to you.

You must carry the original copy of the Limited Driving Privilege Notice with you when operating a motor vehicle.

Form

4595

Missouri Department of Revenue

Application for Limited Driving Privilege

Limited Driving Privilege Reasons

Applicant is requesting a limited driving privilege for the following reason(s): (Must select at least one box)

r Employment (Must provide name and address of employer(s) or if self-employed, name and address of business and type of

employment.) ______________________________________________________________________________________

__________________________________________________________________________________________________

r Education (Must provide the school(s) name and address.) ______________________________________________________

___________________________________________________________________________________________________________

r Attending a Substance Abuse Traffic Offender Program (SATOP) (Provide name and address of alcohol or drug treatment

program, if known.) ___________________________________________________________________________________________

___________________________________________________________________________________________________________

rTo and from a certified ignition interlock device (IID) service facility

rSeeking medical treatment

Being unable to operate a motor vehicle will result in a hardship to the applicant because traveling is required:

rTo and from child care (Must provide child care provider(s) name and address.)____________________________________

___________________________________________________________________________________________________________

rTo and from bank (Must provide the name and address of the bank.) _____________________________________________

___________________________________________________________________________________________________________

rTo transport child or children to and from school(s) (Must provide the school(s) name and address.) __________________

___________________________________________________________________________________________________________

rTo transport child or children to and from spousal or guardian visitation (Must provide the address.) __________________

___________________________________________________________________________________________________________

r OTHER ____________________________________________________________________________________________________

___________________________________________________________________________________________________________

rTo and from grocery store rTo and from gas station rTo seek employment

rTo and from pharmacy rTo and from court obligations rTo and from church

The applicant must have proof of insurance (i.e., SR-22) on file with the Director of Revenue when submitting this application.

Proof of Ignition Interlock Device (IID) service or installation must also be provided if applicable.

Applicant’s Signature Date of Application (MM/DD/YYYY)

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Sign

Mail to: Driver License Bureau Phone: (573) 526-2407

P.O. Box 200 Fax: (573) 522-8795

Jefferson City, MO 65105-0200 E-mail: [email protected]

Visit http://dor.mo.gov/drivers/ldp.php

for additional information.

Form 4595 (Revised 02-2017)

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