OHIO DEPARTMENT OF PUBLIC SAFETY BUREAU OF MOTOR VEHICLES APPLICATION FOR RESTRICTED CDL FOR FARM RELATED SERVICE INDUSTRIES INSTRUCTIONS: RESTRICTED CDL FOR FARM RELATED SERVICE INDUSTRIES - This application applies to seasonal CDL drivers 1) Farm retail outlets and suppliers; 2) Agri-chemical businesses; 3) Custom harvesters and 4) Livestock feeders. The waiver allows a seasonal driver to obtain a restricted Class B CDL license without written / skills testing. This restricted license is limited to a seasonal period not to exceed 180 days in any 12-month period and requires a $25.00 application fee. Each application period must be a minimum of thirty (30) days and no more than 180 days. Applications submitted more than 90 days prior to the beginning of the seasonal period will not be accepted. Applicants must be 18 years old or older to apply. Applicants that currently hold a commercial driver license, other than a Restricted CDL for farm related service industries, are not eligible to apply. Please complete the entire application and return with a CHECK or MONEY ORDER for $25.00 payable to: Ohio Treasurer of State. DO NOT SEND CASH. Mail the application and check or money order to: Ohio Bureau of Motor Vehicles, Attn: CDL UNIT, P.O. Box 16784, Columbus, Ohio 43216-6784. INCOMPLETE APPLICATIONS AND APPLICATIONS WITHOUT THE $25.00 FEE WILL DELAY PROCESSING. SECTION 1: PERSONAL DATA LAST NAME PREVIOUS NAME IF CHANGED RESIDENCE ADDRESS (STREET) CITY STATE ZIP COUNTY FIRST NAME MIDDLE NAME TELEPHONE # MAILING ADDRESS IF DIFFERENT THAN RESIDENCE (STREET) CITY STATE ZIP COUNTY FILL IN THIS SECTION ACCORDING TO YOUR CURRENT LICENSE STATE WHERE LICENSE ISSUED BIRTHDATE CLASS EXP. DATE SEX ENDORSEMENT HEIGHT RESTRICTIONS EYES SOCIAL SECURITY # OR DRIVER LICENSE # WEIGHT SECTION 2: CHECK ALL THAT APPLY Farm retail outlet and / or supplier Agri-chemical business Custom harvester Livestock feeder Each period must be a minimum of 30 days. The total number of days is not to exceed 180 days in any twelve-month period. Examples: Continuous Seasonal Dates: April 1 ­ September 27 (180 days) Split Seasonal Dates: March 15 ­ April 14 (30 days) & June 1 ­ October 28 (150 days) for a combined total of 180 days NOTE: ALL SPLIT SEASONAL DATES REQUIRE A SEPARATE APPLICATION AND $25.00 FEE FOR EACH PERIOD REQUESTED. INDICATE THE BEGINNING AND ENDING DATES BELOW FROM: TO: BMV 2170 3/15 [760-1491] Page 1 of 2 RESTRICTED American LegalNet, Inc. www.FormsWorkFlow.com SECTION 3: DRIVER LICENSE RECORDS Answer all questions below by checking the appropriate box. 1. I hereby certify that my driving privileges are currently valid and not suspended, revoked, cancelled, or disqualified in this or any other state. 2. I have operated a motor vehicle in the one year period immediately preceding today's date. Yes Yes No No SECTION 4: CHECK THE APPROPRIATE BOX FOR EACH STATEMENT ALL QUESTIONS MUST BE ANSWERED - NO EXCEPTIONS: I certify that the answers to the following questions are correct and apply to my driving history for the two (2) year period immediately preceding this application for a Restricted CDL. 1. Have you had a driver license in more than one state at the same time? 2. Has your driver license been suspended, revoked, cancelled, or disqualified in this or any other state? 3. Have you been convicted in any type of motor vehicle for: A. Driving while intoxicated, driving while under the influence of alcohol (includes BAC) or driving while under a controlled substance. B. Leaving the scene of an accident. C. A felony involving the use of a commercial motor vehicle. D. Speeding 15 or more MPH over the posted speed limit. E. Reckless operation. F. Following too closely. G. Improper lane change / lane violation. H. A violation of vehicular homicide. 4. Have you been convicted of any county or municipal ordinance, or any state law relating to the operation of any type of motor vehicle in connection with an at-fault crash? 5. Have you refused to submit to any test of your blood, breath, or urine for the purpose of determining alcohol concentration or the presence of a controlled substance? 6. Have you violated an out of service order? 7. Have you violated any of the prohibitions described above while transporting hazardous materials? Yes Yes No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No SECTION 5: ANSWER THE FOLLOWING DRIVER INFORMATION MARK THE TYPE OF VEHICLE YOU WILL BE DRIVING Straight Truck Gross Vehicle Weight Rating (GVWR) Power Unit GVWR Trailer Yes No Air Brake Equipped? Vehicle designed to carry 16 persons or more, including the driver. Air Brake Equipped? Yes No SECTION 6: Each application for a Restricted CDL requires a fee of $25.00. Ibs. GVWR APPLICANT'S SIGNATURE If I make a false statement on this application and am issued a Restricted Commercial Driver License, I understand that my license will be cancelled upon discovery and that I will not be permitted to make APPLICATION FOR ANY TYPE OF LICENSE FOR A PERIOD OF ONE YEAR. ANY PERSON GIVING FALSE INFORMATION IS SUBJECT TO PROSECUTION UNDER SECTIONS 4506.10 AND 4507.36 OF THE OHIO REVISED CODE. APPLICANT'S SIGNATURE TODAY'S DATE X BMV 2170 3/15 [760-1491] Page 2 of 2 RESTRICTED American LegalNet, Inc. www.FormsWorkFlow.com