ß Ð«¾´·½ Í»®ª·½» ß¹»²½§ APPLICATION FOR CRITICAL NEED RESTRICTION [California Vehicle Code (CVC) §13353.8(a)] *DS694* Submit COMPLETED application to the Driver Safety Actions Unit, 2570 24th Street, M/S J256, Sacramento, CA 95818, Telephone: (916) 657-6452. Department of Motor Vehicles (DMV) approval is required prior to issuance of a restricted license. If approved, ATTACH SEPARATE SHEET IF MORE SPACE IS NEEDED. HARDSHIP conditions are shown to exist. ALL other SECTION 1 -- STATEMENT OF FACTS BY APPLICANT (OR PARENTS, IF UNDER 18 YEARS OF AGE) A. ( PART A -- DESCRIPTION OF CURRENT TRANSPORTATION AND NEEDS ) ( ZIP CODE ) (IF MEDICAL REASON, SEPARATE STATEMENT OF FACTS BY PHYSICIAN NEEDED.) PART B -- ADDITIONAL INFORMATION REQUIRED IF REQUEST IS DUE TO FAMILY ILLNESS PART C -- ADDITIONAL INFORMATION REQUIRED IF REQUEST IS BASED ON NEED FOR TRANSPORTATION TO AND FROM SCHOOL PART D -- ADDITIONAL INFORMATION REQUIRED IF REQUEST IS BASED ON NEED FOR TRANSPORTATION TO AND FROM WORK $ Per $ Per PART E -- ADDITIONAL INFORMATION REQUIRED IF REQUEST IS BASED ON FAMILY ENTERPRISE (INCLUDE FAMILY MEMBERS) ÜÍ êçì øÎÛÊò ëñîðïê÷ ÉÉÉ American LegalNet, Inc. www.FormsWorkFlow.com (IF ANY) AUTHORIZATION AND CERTIFICATION: (If under 18 years of age, both parents must sign) I/We certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct. sole custody." ZIP CODE X ZIP CODE X ZIP CODE X SECTION 2 -- STATEMENT OF FACTS BY PHYSICIAN Physician must complete a separate statement for each family member whose disability affects driving or transportation needs YES Yes SECTION 3 -- STATEMENT OF FACTS BY SCHOOL PRINCIPAL OR DEAN School principal or dean must complete if hardship condition is to and from school. If hardship condition is to and from college, submit a printout of current schedule, including days and hours of all classes in which enrolled. SECTION 4 -- STATEMENT OF FACTS BY EMPLOYER (Employer must complete if hardship condition is to and from work.) $ Per Yes SECTION 5 -- CERTIFICATION TO BE COMPLETED BY: Physician School Principal or Dean Employer I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct. (PRINT OR TYPE) ZIP CODE X ( ) ÜÍ êçì øÎÛÊò ëñîðïê÷ ÉÉÉ American LegalNet, Inc. www.FormsWorkFlow.com