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 IMPAIRED DRIVING (OUT-OF-STATE OR FEDERAL Height Date Of Birth Weight Drivers License No. And State Date Of Conviction Race Hair Color Date Of Offense Sex Eye Color CONVICTIONS) G.S. 20-179.3 NOTE: THIS IS A CIVIL ACTION. Use this form when the applicant's license is revoked because of a conviction in another jurisdiction substantially similar to impaired driving under G.S. 20-138.1. FINDINGS Upon application of the applicant for a limited driving privilege, the Court finds that: 1. The applicant's North Carolina drivers license is revoked because of a conviction in another jurisdiction on a charge substantially similar to impaired driving under G.S. 20-138.1; 2. The applicant would be eligible for a limited driving privilege if the conviction had occurred in North Carolina and, if applicable, the period of nonoperation has expired; 3. 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; and 4. (check only one) a. The Court has been furnished a properly executed form DL-123 and is satisfied that the applicant is financially responsible. b. The applicant has executed form DL-123A and is not required to furnish proof of financial responsibility. 5. The applicant has has not satisfied the eligibility requirements under G.S. 20-179.3 at this time. ORDER 1. 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 of this form, and to expire one year from the date on which the Division of Motor Vehicles revoked the applicant's drivers license pursuant to G.S. 20-23. This limited driving privilege is conditioned upon the maintenance of financial responsibility as required by G.S. 20-179.3(l) during the period of this privilege. 2. It is ORDERED that the applicant NOT be allowed a limited driving privilege at this time. Effective Date Date Signature Of Chief District Court Judge Name Of Chief District Court Judge (Type Or Print) NOTE TO DEFENDANT: This privilege is no longer valid after the revocation period for the offense of which you were convicted has ended, or if your drivers license remains revoked solely because the Division of Motor Vehicles has not obtained a certificate of your completion of a substance abuse treatment program or an alcohol and drug education traffic school. AOC-CV-352, Rev. 10/15 © 2015 Administrative Office of the Courts Original-File Certified Copy-Defendant (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. The 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 assessment or 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: Other: (specify) Corrective Lenses 45 M.P.H. Only Daylight Only Name And Address Of ADET School, Community Service Coordinator, Or Mental Health Name And Address Of Employer Or Driver's Place Of Work Treatment Facility To Which Driver Assigned 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; that if community service has been ordered, my willful failure to pay the prescribed fee or complete the community service within the time limit imposed shall result in revocation of this Limited Driving Privilege; and that my willful failure may also result in other action authorized by law for violation of a condition of probation. Date Signature Of Applicant CERTIFICATION I certify that this is a true and complete copy of the original on file in this case. Date Signature Assistant CSC Deputy CSC Clerk Of Superior Court AOC-CV-352, Side Two, Rev. 10/15 © 2015 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com