Transcription of Form 4595 - Application for Limited Driving Privilege
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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
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
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