MV-58A (4/11) New York State Department of Motor Vehicles CERTIFICATE OF EMPLOYMENT I certify that ___________________________________________________ _______________________ is employed by me (Name of Licensee) (License ID #) at ________________________________________________ __________________________________________________. (Name of Business) (Address of Business) If I am asked to do so by a police officer or magistrate, I will verify that these days and hours are correct. I can be reached at __________________________________________________________________ ____________________________ (Address) (Telephone Number) Signature and Title of Employer ____________________________________________________________________ ______________________ ç (Date) HOURS OF EMPLOYMENT ARE: Mon. Tues. Wed. Thurs. Fri. Sat. Sun. FROM " (SEPARATE THE TOP AND BOTTOM PARTS HERE.) " TO INSTRUCTIONS The employer of a person holding a Class DJ or MJ license or Limited Class DJ or MJ license must complete this certificate to allow the employee to drive to and from work unaccompanied by another licensed driver during specific hours. The licensee must work at least once a week for at least four consecutive weeks. The license holder must carry this certificate at all times when driving to and from work. After separating the top of this form from the bottom, the licensee should fold the top part and keep it with his/her driver license. RESTRICTIONS This certificate is not valid for driving during the hours of employment (for example, to make deliveries or engage in sales) except for farm employment as indicated below. This certificate is not valid for driving in New York City at any time. This certificate allows the Class DJ and Class MJ licensee to drive to and from his/her place of employment after 9 p.m. except in New York City, Nassau and Suffolk counties. In Nassau and Suffolk counties, this certificate allows the Class DJ and Class MJ licensee to drive to and from his/her place of employment only between 5 a.m. and 9 p.m; it also allows the licensee to drive while engaged in farm employment at any time. This certificate allows the Limited Class DJ and Limited Class MJ licensee to drive to and from his/her place of employment anytime, except in New York City, Nassau, Suffolk, Westchester, Rockland and Putnam counties. With a Limited Class DJ or Limited Class MJ license, this certificate cannot be used at any time to drive in New York City, Nassau, Suffolk, Westchester, Rockland and Putnam counties. MV-58A (4/11) www.dmv.ny.gov American LegalNet, Inc. www.FormsWorkFlow.com