IN THE MAUMEE MUNICIPAL COURT REQUEST FOR LIMITED DRIVING PRIVILEGES (which includes occupational, educational, vocational and medical purposes as well as for the purpose of taking the driver’s or commercial driver’s license examination) Section 4510.021 O.R.C. Name __________________________________________ Case No. _______________ Address ________________________________________________________________ City/State/Zip ___________________________________________________________ Name of Employer _________________________________________________________ Name of Supervisor ______________________________________________________ Address of Employer ______________________________________________________ City/State/Zip _____________________________________________________________ Nature of Employment (title, position, job description, etc.): _____________________________________________ ____________________________________________________________________________ What days and hours of the week do you work? ____________________________________ ____________________________________________________________________________ Do you work overtime? _____ Yes _____ No Do you operate a motor vehicle as part of your employment? _____ Yes _____ No Any additional information: _______________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Executed and signed this ________ day of ______________________, ________, who verifies that the above statements are true. ____________________________________ Petitioner's Signature __________________________________ Telephone Number American LegalNet, Inc. www.FormsWorkFlow.com