STATE OF NORTH CAROLINA County Name And Address Of Applicant File No. In The General Court Of Justice District Superior Court Division IN THE MATTER OF: LIMITED DRIVING PRIVILEGE INDEFINITE PRETRIAL REVOCATION Height Date Of Birth Weight Drivers License No. Date Of Revocation If Different From Offense Date Race Hair Color Date Of Offense Sex Eye Color (IMPLIED-CONSENT OFFENSE) G.S. 20-16.5 State NOTE: Use this form only for revocations under G.S. 20-16.5, and only when the revocation is indefinite. FINDINGS Upon application of the defendant for a limited driving privilege, the Court finds that: 1. The defendant's license is currently revoked under G.S. 20-16.5, and the revocation is for an indefinite period. 2. At the time of the alleged offense, the applicant held either a valid drivers license or a license that had been expired for less than one year. 3. On (name date) , the applicant surrendered his/her license as defined in G.S. 20-16.5(a)(5). OR demonstrated that he/she was not currently licensed at the time of the offense. 4. At the time of the alleged offense the defendant had not within the preceding seven (7) years been convicted of an offense involving impaired driving. 5. Subsequent to the alleged offense, the defendant has not been convicted of, or had an unresolved charge lodged against him/her for, an offense involving impaired driving. 6. a. The applicant was present when the applicant's drivers license was revoked for the current offense, and the applicant has completed thirty (30) days of the revocation period. b. The applicant was not present when the applicant's drivers license was revoked for the current offense but surrendered that license within five (5) working days after the effective date of the revocation order, and the applicant has completed thirty (30) days of the revocation period. c. The applicant was not present when the applicant's drivers license was revoked for the current offense and did not surrender that license within five (5) working days after the effective date of the revocation order, and the applicant has completed forty-five (45) days of the revocation period. 7. The defendant has obtained and filed with the court a substance abuse assessment conducted by one of the entities authorized by the Department of Health and Human Services to conduct assessments. 8. Allowance of a limited driving privilege to the defendant is necessary to overcome undue hardship. 9. The records of the Division of Motor Vehicles and the Clerk of Superior Court in this county have been searched and there are no other revocations in effect at this time. ORDER It is ORDERED that the applicant be allowed a limited driving privilege to be effective on the date indicated below to be used in accordance with the restrictions imposed on the reverse side of this form, and to expire on the expiration date shown below. This limited driving privilege is conditioned upon the maintenance of any financial responsibility required by G.S. 20-179.3(l) during the period of this privilege. NOTE: This privilege will expire on the earlier of any date specified in this order or the date on which a final judgment, including appeals, has been entered on all implied consent offenses pending against the defendant on the date of this privilege. Effective Date Date Name Of District Court Judge (Type Or Print) Expiration Date Signature Of District Court Judge AOC-CVR-11, Rev. 10/15 � 2015 Administrative Office of the Courts Original - File Certified Copy - Applicant (Over) Copy - DMV American LegalNet, Inc. www.FormsWorkFlow.com RESTRICTIONS The driver shall not drink alcohol while driving or drive while any alcohol remains in his/her body. The driver shall not drive while having a controlled substance in his/her body unless such controlled substance was lawfully obtained and taken in therapeutically approved amounts. This limited driving privilege DOES NOT include the privilege of operating a commercial motor vehicle as defined in G.S. 20-4.01(3d). Driving when essential for emergency medical care is authorized at any time. Standard working hours are from 6 AM to 8 PM, Monday - Friday. Driving, other than for emergency medical care, is permitted only as follows: (check only applicable boxes) 1. Driving is permitted for work-related, religious worship, or educational purposes during standard working hours as follows: 2. Driving is permitted for maintenance of household during standard working hours as follows: 3. Driving is permitted for work-related, religious worship, or educational purposes during nonstandard working hours as follows: The driver is self employed and the required documentation for work-related driving is attached. 4. Driving is permitted for community service assignment, Alcohol and Drug Education Traffic School, and substance abuse treatment as follows: 5. Driving is restricted to: a. any non-commercial vehicle registered in the name of the driver. b. the following non-commercial vehicle(s): The above vehicle shall be equipped with a functioning ignition interlock system of a type approved by the Commissioner of Motor Vehicles and the defendant shall personally activate the ignition interlock system before operating the vehicle. The driver may drive to and from any ignition interlock service facility for installation and service purposes. 6. Additional restrictions: Corrective Lenses 45 M.P.H. Only Daylight Only Other: Name And Address Of ADET School, Community Service Coordinator, Or Mental Health Treatment Facility To Which Driver Assigned Name And Address Of Employer Or Driver's Place Of Work NOTICE/ACKNOWLEDGMENT OF RECEIPT I have received a copy of this limited driving privilege which contains the restrictions on my driving privilege. I understand that if I drive with the odor of alcohol on my breath, I may be subject to arrest and loss of this limited driving privilege; I understand that this is my limited license to drive; that I must keep it in my possession during the period of revocation; that if my drivers license is revoked for any other reason, this limited driving privilege is invalid; that a violation of any restriction imposed in connection with this limited driving privilege constitutes the offense of driving while license revoked under G.S. 20-28. Date Signature Of Defendant CERTIFICATION I certify that this is a true and complete copy of the original on file in this case. Date Signature Deputy CSC Clerk Of Superior Court Assistant CSC AOC-CVR-11, Sid