IN THE MUNICIPAL COURT OF VANDALIA, OHIO CIVIL DIVISION Name Address City State Zip Code SSN XXX-XXDOB Petitioner, vs. REGISTRAR BUREAU OF MOTOR VEHICLES P.O. BOX 16520 COLUMBUS, OH 43266 Defendant. : : CASE NO. CVH_________________ (last 4) : : : : : : : APPEAL OF 12-POINT LICENSE SUSPENSION Petitioner hereby requests driving privileges while under a 12-point suspension. NO DRIVING PRIVILEGES ARE GRANTED HEREIN FOR ANY COMMERCIAL MOTOR VEHICLE FOR WHICH A CDL IS REQUIRED (4506.161 ORC) Petitioner represents that the civil filing fee for the Petition has been paid and has been advised that said filing fee is NON-REFUNDABLE ___________________________ PETITIONER'S SIGNATURE ________________________________ PETITIONER'S PHONE NUMBER American LegalNet, Inc. www.FormsWorkFlow.com NAME: ADDRESS: DOB: SSN: OLN: PLACE OF EMPLOYMENT: ADDRESS OF EMPLOYER: POSITION/TITLE: DUTIES: SUPERVISOR'S NAME: SUPERVISOR'S PHONE NO.: DAYS OF WEEK SCHEDULED TO WORK TIME OF DAY SCHEDULED TO WORK TIME TO DRIVE TO WORK (ONE-WAY) REQUIRED TO DRIVE DURING WORK HOURS? IF SO, DO YOU DRIVE A COMPANY VEHICLE? YES / NO YES / NO American LegalNet, Inc. www.FormsWorkFlow.com