IN THE GENERAL SESSIONS CRIMINAL COURT SHELBY COUNTY, TENNESSEE STATE OF TENNESSEE ARREST DATE: ______________________________________________________ vs. DWI CONVICTION DATE: _____________________________________________ _______________________________________________________ DOCKET NO.: _______________________________________________________ (FULL NAME) (NOTICE TO COURT CLERK: PLEASE ATTACH COURT ABSTRACT) DATE OF BIRTH: ________________________________________ OTHER DISPOSITION & DATE: ________________________________________ DRIVERS LICENSE NO.: __________________________________ (Implied cons) ent cases ( STATE) ORDER Upon application of the defendant for a restricted drivers license, and it appearing to the court that the def endant has been convicted in this Court of DWI (TCA 55-10-403), or suspended under the Implied Consent Law (TCA 55-10-406), and it further appearing to the Court that the defendant needs a restricted drivers license for the purpose of driving to and from work and while in the actual performance of the duties of said employment. HOUSE ADDRESS: ____________________________________________________________________________________________________________________________ EMPLOYER (NAME & ADDRESS): ______________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ WORK LOCATION (IF DIFFERENT FROM EMPLOYERS ADDRESS): ________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________ WORK HOURS: _______________________________________________________________________________________________________________________________ DRIVING PRIVILEGES AUTHORIZED BY COURT: _________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ It is, therefore, ORDER tEhatD the defendant be issued a restricted drivers license for the purpose set forth above, subject to the rules and regulations of the Department of Safety of the State of Tennessee. This _________________________________ day of ________________________________ yr __________________ ____________________________________________________________________ ( JUDGE) ____________________________________________________________________ ( COURT) INSTRUCTIONS FOR ISSUANCE OF RESTRICTED DRIVERS LICENSE 1. This form must be delivered to Drivers License Examining Station of your choice within thirty (30) day sand pres of this Centourt w Orderith (2) copies of the Order to the Drivers License Examiner along with proof of liability insurance. Acceptable proof of insurance may be a liabilitpolicy or wy insrittuen vrancee rification from an insurance company or agency certifying that you are covered with insurance (applications for insurance cannot be acctepting ted).he C Afourtter Order,presen an acceptable proof of insurance, and upon passing the required drivers license examination, consisting of eye, written, and road triveing permst, a temitporary will be is dsued. One (1) copy of the Court Order will be returned to you to keep with your temporary driving permit until you receive yicour resense. tricted drivers l 2. An SR-22 form must be attached to this restricted drivers license from when it is delivered to Drivers Lictatienson ie fEx coamnvining icted oSf DWI. This form verifies your insurance coverage to the Department of Safety. In order for your restricted drivers license to be mailed tormo y mou,us tt be reche SR-22 feived in Nashville within 45 days from the date of your drivers license test. The SR-22 requirement applies to DWIs only, not to those suspended on Implied Consent. 3. Upon successfully passing the examination and paying the required fees to the Examiner (the fees of sixt my-suesvt be paid in cen (67) dollarsash only), the Examiner will issue a temporary restricted license valid not to exceed sixty (60) days. As soon as the SR-22, if required,ashv isille, rec tehe Dived in Nepartment of Safety will mail to you a restricted license valid for the period of the suspension or revocation imposed by law. 4. You must be covered by liability insurance at all times to drive legally on a restricted license. We are providing you with this information to expedite the issuance of your license.