Original - Court 1st copy - Secretary of State 2nd copy - Petitioner 3rd copy - Attorney General/Prosecutor Approved, SCAO STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY CASE NO. ORDER REGARDING DRIVER'S LICENSE RESTORATION Court address Court telephone no. Petitioner's name, address, and telephone no. Respondent v Driver's license no. Date of birth Petitioner's attorney, bar no., address, and telephone no. Date of hearing: 1. On SECRETARY OF STATE OF THE STATE OF MICHIGAN Driver Assessment and Appeal Division PO Box 30196 Lansing, Michigan 48909-7696 Respondent's attorney, bar no., address, and telephone no. Judge: Bar no. petitioner filed a petition for review of the Date a. Date (For arrests on or after 10/1/99.) application denial for medical reasons (MCL 257.303[1][d]). driver assessment suspension, restriction (not a revocation) (MCL 257.310d, MCL 257.320). first implied consent suspension (MCL 257.323[3] and MCL 257.625f). mandatory additional suspension for driving while license suspended (not a revocation) (MCL 257.904[10]or [11]). second implied consent suspension (MCL 257.323[4] and MCL 257.625f). b. (For arrests from 1/1/92 through 9/30/99.) licensing action . IT IS ORDERED: 2. The Secretary of State shall restore a driver's license with full privileges to the petitioner. 3. The Secretary of State shall issue restricted driving privileges as follows. a. The petitioner may drive to and from the residence and place of employment and in the course of employment, to a substance abuse treatment program and/or support group meetings, to regularly scheduled treatment for a serious medical condition, to the probation office and community service, and to an educational institution. The petitioner must carry proof of destination and hours. b. If there is any evidence of drinking while using a motor vehicle, or if there is a violation of this order during the period that this order is in effect, police shall confiscate the driver's license and return it to the court. A hearing will be held if requested by the petitioner within 14 days from the date the license is confiscated. c. Provided the petitioner abides by the conditions of this order, the restricted driver's license shall terminate on AND on that date the petitioner shall appear before the court for further examination and review. OR the court relinquishes jurisdiction to the Secretary of State. OR on that date the Secretary of State shall restore full driving privileges. 4. The petitioner's appeal for licensing privileges is denied. 5. Any relief granted in this order is effective only for an action listed in item 1 above. (continued on other side) CC 268 (3/08) ORDER REGARDING DRIVER'S LICENSE RESTORATION MCL 257.323, MCL 257.323a-c American LegalNet, Inc. www.FormsWorkflow.com 6. This order shall be void and without effect if a certified copy of this order is not served on the Secretary of State, Driver Assessment and Appeal Division, PO Box 30196, Lansing, Michigan 48909-7696 within 7 days of the date this order is signed. Date Judge Approved as to form: Assistant attorney general/Assistant prosecuting attorney CERTIFICATE OF MAILING I certify that on this date I served a copy of this order on the parties or their attorneys by first-class mail addressed to their last-known addresses as defined in MCR 2.107(C)(3). Date Signature American LegalNet, Inc. www.FormsWorkflow.com