Application for Non-Commercial Restricted Diver License
I am applying for a non-commercial license restriction to drive to and from my place of employment, and/or
during my employment and the type of vehicle being operated does not require a Class A, B, or commercial
Class C license.
NOTE: (1) This restriction allows driving of any insured vehicle to and from your job, and/or on the job.
(2) If you are required to drive your employer’s vehicle on the job you are not suspended when driving
a vehicle during your employment, if the vehicle is not registered to you (§16073 VC) and the type
of vehicle being operated does not require a Class A, B, or commercial Class C license.
I am applying for a restriction to drive my minor dependent _______________________________________
from my home to school and from school to home, because no public or school bus transportation is available.
The school principal or adminisTraTor is To compleTe This porTion.
I certify that, to the best of my knowledge and belief, no form of public transportation or school bus is available
between the applicant’s residence and this school.
1. APPLICATION
I am applying for a restriction due to the following health problem requiring more than one treatment:
2. MEDICAL AUTHORIZATION (Complete only if you will be driving yourself to and from treatment)
I authorize my practitioner, hospital, or medical facility to release to the Department of Motor Vehicles (DMV), its
agents, or employees information and records relating to my physical and/or mental condition, both verbally and
in writing. I agree to pay for any expense involved in releasing the records.
3. MEDICALEVALUATION(MedicalinformationiscondentialperVehicleCode§1808.5)
DMV seeks the benet of your experience and knowledge of the above named patient’s condition and the course
of treatment. This information will be used by DMV solely in evaluating the request for a restricted driver license
and the restriction applicant’s ability to drive safely. Please answer all questions.
I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
APPLICANT
INFORMATION
Part A
TO, FROM &
DURING
EMPLOYMENT
RESTRICTION
(52)
Part B
SCHOOL
TRANSPORTATION
FOR DEPENDENT
MINOR
RESTRICTION
(92)
Part C
MEDICAL
TREATMENT
RESTRICTION
For driving:
(check only
one box)
Self
(51)
Family
Member
(91)
Both Self and
Family
Member
(51 & 91)
Part D
APPLICANT’S
CERTIFICATION
DMV USE ONLY
BRIEF DESCRIPTION OF HEALTH PROBLEM TREATMENT ExPECTED FINAL TREATMENT DATE
ADDRESS wHERE TREATMENTS wILL BE ADMINISTERED
CITY STATE zIP CODE
IN YOUR PROFESSIONAL OPINION, wOULD APPLICANT’S CONDITION AND/OR TREATMENT BE LIkELY TO AFFECT HIS/HER DRIVING ABILITY?
DATE PRACTITIONER’S SIGNATURE PRACTITIONER’S PRINTED NAME PROFESSIONAL LICENSE NO.
PRACTITIONER’S ADDRESS TELEPHONE NUMBER
CITY STATE zIP CODE
PATIENT’S NAME PATIENT’S RELATIONSHIP TO DRIVER TYPE OF HEALTH PROBLEM
NAME OF TREATMENT CENTER, HOSPITAL, OR MEDICAL FACILITY
ADDRESS OF TREATMENT CENTER, HOSPITAL, OR MEDICAL FACILITY
CITY STATE zIP CODE
APPLICANT’S NAME DRIVER LICENSE NUMBER
ADDRESS TELEPHONE NUMBER
CITY STATE zIP CODE
A Public Service Agency
NAME OF SCHOOL TELEPHONE NUMBER
SCHOOL ADDRESS
CITY STATE zIP CODE
DATE SIGNATURE OF PRINCIPAL OR ADMINISTRATOR PRINTED NAME AND TITLE OF PRINCIPAL/ADMINISTRATOR
X
DATE SIGNATURE MEDICAL RECORD/FILE NUMBER
X
X
No Yes (If Yes, please explain)
DATE SIGNATURE
X
AUTHORIzED DMV EMPLOYEE Refer to DS Ofce LINE DATE/SEqUENCE
APPROVED
DENIED
PRIMARY
SECONDARY
NAME GRADE
( )
( )
(IF SELF, COMPLETE PART 2 BELOw)
( )
DL 691 (REV. 12/2007) WWW
APPLICATION FOR non-commercial RESTRICTED
DRIVER LICENSE FOR FINANCIAL RESPONSIBILITY ACTIONS
(See back forGeneralInformationandInstructions)
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