Transcription of Form 4595 - Application for Limited Driving Privilege
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Example: bachelor of science
Form 4595 - Application for Limited Driving Privilege
Driver License Number Date of Birth (MM/DD/YYYY) ___ ___ / ___ ___ / ___ ___ ___ ___Name (Last, First, Middle Initial) Social Security Number | | | | | | | | Street Address (Do not use Box) City, State, ZIP CodeMailing Address (If different from street address) City, State, ZIP CodeE-mail Address
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.)_____
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