IN THE MUNICIPAL COURT OF VANDALIA, OHIO CIVIL DIVISION NAME ADDRESS CITY STATE ZIP CODE SSN DOB : : : XXX-XX(last 4) : Petitioner, -vsREGISTRAR BUREAU OF MOTOR VEHICLES P.O. BOX 16520 COLUMBUS, OH 43216 : : : : PETITION FOR OCCUPATIONAL DRIVING PRIVILEGES FROM AN ADMINISTRATIVE LICENSE SUSPENSION CASE NO. CVH___________________ : Respondent. ______________________________________________________________ Petitioner received an Administrative License Suspension on the ______ day of ____________________, 20____, Traffic Case No. ____________________ for a period of _________________________. Petitioner hereby requests the Court to modify said suspension so as to grant occupational driving privileges on the grounds that said suspension would seriously affect the Petitioner's ability to continue in his/her employment. Petitioner represents that he/she is under no other license suspension of driving privileges 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. ___________________________________ Attorney for Petitioner/Petitioner ___________________________________ Printed Name and Supreme Court Number ___________________________________ Address ___________________________________ 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