File No. LIMITED DRIVING PRIVILEGE - SPEEDING, RECKLESS DRIVING, AGGRESSIVE DRIVING, LARCENY OF MOTOR FUEL, UNSAFE MOVEMENT, FAILURE TO MOVE OVER, OR PASSING STOPPED SCHOOL BUS - IN-STATE CONVICTIONSG.S. 14-72.5(c); 20-16(a)(9), (a)(10), (a)(10a), (e1), (e2); 20-16.1; 20-17(a)(16); 20-154(a2); 20-157(i); 20-217(g1) STATE OF NORTH CAROLINA CountyIn The General Court Of Justice District Superior Court DivisionSTATE VERSUS Type Of Vehicle Corrective Lenses Daylight Only (specify) Date Of OrderEffective FromToSignature Of JudgeName Of Judge (type or print) SignatureDate Deputy CSC Asst. CSC Clerk Of Superior Court Signature Of Defendant DateDate(s) Of Conviction(s) NOTICE/ACKNOWLEDGMENT OF RECEIPT Name And Address Of DefendantGeographical RestrictionDriving Hours Allowed NOTE: Use this form in appropriate circumstances to issue a limited driving privilege when the defendant222s license is suspended/revoked under one of the following provisions:- G.S. 20-16(a)(9) (speeding, reckless driving, aggressive driving) where at least one of the convictions occurred in NC. If the convictions occurred in outside NC (i.e., in another state or in federal court), use AOC-CV-350 and AOC-CV-351.- G.S. 20-16(a)(10) (speeding in excess of 75 m.p.h. where maximum speed is less than 70 m.p.h.) where the conviction occurred in NC. If the conviction occurred in another state or in federal court, use AOC-CV-350 and AOC-CV-351.- G.S. 20-16(a)(10a) (speeding in excess of 80 m.p.h. where maximum speed is 70 m.p.h.) where the conviction occurred in NC. If the conviction occurred in another state or in federal court, use AOC-CV-350 and AOC-CV-351.- G.S. 20-16.1(a) (speeding more than 15 m.p.h. over speed limit at speed in excess of 55 m.p.h., or speeding in excess of 80 m.p.h.) where the conviction occurred in NC. If the conviction occurred in another state or in federal court, use AOC-CV-350 and AOC-CV-351.- G.S. 20-17(a)(16) (second or subsequent conviction of larceny of motor fuel under G.S. 14-72.5).- G.S. 20-154(a2) (unsafe movement resulting in property damage in excess of $5,000 or serious bodily injury to a motorcycle or bicycle operator or passenger).- G.S. 20-157(i) (violation of G.S. 20-157 causing serious injury or death).- G.S. 20-217(g1)Applies to offenses committed on or after December 1, 2013. ORDER FINDINGS Eye ColorDate Of BirthRaceSexHeightWeight Hair ColorOffense(s) For Which Defendant Was ConvictedDrivers License No. And State CERTIFICATION American LegalNet, Inc. www.FormsWorkFlow.com