STATE OF NORTH CAROLINA County Name And Address Of Applicant File No. In The General Court Of Justice District Court Division IN THE MATTER OF: LIMITED DRIVING PRIVILEGE PRETRIAL REVOCATION Race Hair Color Date Of Offense Sex Eye Color Height Date Of Birth Weight Drivers License No. Date Of Revocation If Different From Offense Date (IMPLIED-CONSENT OFFENSE) G.S. 20-16.5 State NOTE: Use this form only for revocations under G.S. 20-16.5. 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. 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 20-16.5(a)(5). OR demonstrated that he/she was not currently licensed at the time of the offense. 4. The applicant does not have any unresolved pending charges involving impaired driving except for the charge which led to this current revocation under G.S. 20-16.5. 5. The applicant has not had any convictions for an offense involving impaired driving since being charged for the violation for which the license is currently revoked under G.S. 20-16.5. ten (10) days and the minimum period of 6. The applicant's drivers license has been revoked for at least thirty (30) days and the minimum period of revocation is forty-five (45) days. revocation is thirty (30) days. 7. The applicant has obtained and filed with this Court a substance abuse assessment; and has registered for and agreed to participate in any recommended training or treatment program. 8. 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 specified 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. Effective Date Expiration Date Date Signature Of District Court Judge Name Of District Court Judge (Type Or Print) AOC-CVR-10, 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-10, Side Two, Rev. 10/15 © 2015 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com