PORTAGE COUNTY MUNICIPAL COURT LINDA K. FANKHAUSER, CLERK OF COURTS RAVENNA DIVISION KENT DIVISION 203 West Main Street PO Box 958 303 East Main Street Ravenna OH 44266 Kent OH 44240 Civil Div. Ph: 330-297-3635 Civil Div. Ph: 330-678-9170 Fax 330-297-3526 Fax 330-678-5107 Traffic Div. Ph 330-297-3640 Traffic Div. Ph: 330-678-9100 Fax 330-297-5867 Fax 330-677-9944 REQUEST FOR DRIVING PRIVILEGES NAME:__________________________________________________________________________________ ADDRESS:_______________________________________________________________________________ PHONE NUMBER: __________________________________ BIRTHDATE:______________________ ( ) OCCUPATIONAL PRIVILEGES (PROOF REQUIRED) 1ST EMPLOYER: ___________________________________________________________________________ EMPLOYER'S ADDRESS:__________________________________________________________________ SUPERVISOR'S NAME /TELEPHONE NUMBER:_______________________________________________ WORK SCHEDULE HOURS AND DAY, (INCLUDE DRIVE TIMES TO AND FROM WORK)___________ _______________________________________________________________________________________ 2ND EMPLOYER: __________________________________________________________________________ EMPLOYER'S ADDRESS:__________________________________________________________________ SUPERVISOR'S NAME /TELEPHONE NUMBER:_______________________________________________ WORK SCHEDULE HOURS AND DAY, (INCLUDE DRIVE TIMES TO AND FROM WORK)___________ _______________________________________________________________________________________ ( ) EDUCATIONAL/VOCATIONAL PRIVILEGES (CURRENT SCHOOL SCHEDULE IS ATTACHED ) NAME AND ADDRESS OF SCHOOL: ______________________________________________________________________________________ ( ) MEDICAL PRIVILEGES (PROOF REQUIRED) AUTO INSURANCE INFORMATION : (PROOF REQUIRED) INSURANCE COMPANY: _________________________________________________________________ AGENT: ________________________________________________________________________________ POLICY#: ________________COVERAGE PERIOD: _______________TELEPHONE NO: ______________ _________________________________________________ SIGNATURE _________________________________ DATE American LegalNet, Inc. www.FormsWorkFlow.com