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APPLICATION FOR RESTRICTED

Clear All Data APPLICATION FOR RESTRICTED DRIVER'S LICENSE Case No.. Commonwealth of Virginia [ ] General District Court .. [ ] Juvenile & Domestic Relations District Court CITY/COUNTY.. DEFENDANT DRIVER'S LICENSE NUMBER STATE.. ADDRESS DATE OF BIRTH.. CITY STATE ZIP DATE OF OFFENSE.. TELEPHONE NUMBER. My driver's license has been suspended or denied for an offense which makes me eligible for a RESTRICTED (Court use only). driver's license; therefore, I request that the court grant a RESTRICTED driver's license for travel to and from the APPROVED. following locations for the following purpose(s): (a) [ ] Travel to and from primary job Name and Location of Employer: .. [ ] YES [ ] NO.

FORM DC-263 (MASTER, PAGE ONE OF TWO) 10/13 . APPLICATION FOR RESTRICTED DRIVER’S LICENSE. Case No. ..... Commonwealth of Virginia

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