PETITION FOR RESTORATION OF DRIVING PRIVILEGE 226 THIRD OFFENSE TO THE JUDGE OF THE ABOVE-NAMED COURT:CHECK A OR B BELOW TO INDICATE THE BASIS OF YOUR PETITION AND COMPLETE OTHER SECTIONS AS APPLICABLE: If the Court does not restore my privilege to operate a motor vehicle in the Commonwealth as requested above, I further request, as indicated by completing the next section, that the Court authorize the issuance of a restricted license in lieu of restoring my privilege to drive as provided in Va. Code 247 46.2-391(C)(1). I request that the Court grant the restricted driver222s license for travel to and from the following locations for the following purpose(s): American LegalNet, Inc. www.FormsWorkFlow.com Case No. ............................................................. [ ] Travel to/from the facility that installed or monitors the ignition interlock on your vehicle(s), if ignition interlock is ordered. [ ] Travel to/from work [ ] Travel to/from VASAP [ ] Travel during work [ ] Travel to/from school [ ] Travel to/from school for child [ ] Travel to/from day care for child [ ] Travel to/from medical service facility for [ ] you [ ] minor child [ ] elderly parent [ ] person residing in household: ...................................................................... [ ] Travel to/from court ordered visitation with child or children [ ] Travel to/from appointments with probation officer [ ] Travel to/from programs required by court or as a condition of probation [ ] Travel to/from a place of religious worship .................................................................................................................................................................................................................................. NAME AND LOCATION OF PLACE OF WORSHIP .................................................................................................................................................................................................................................. REQUESTED DAY OF WEEK AND TIME FOR TRAVEL [ ] Travel to/from appointments approved by the Division of Child Support Enforcement of the Department of Social Services as a requirement of participation in an administrative or court-ordered intensive case monitoring program for child support [ ] Travel to/from jail to serve a sentence on weekends or nonconsecutive days [ ] Travel to/from a job interview for which you have with you written proof from your prospective employer of the date, time, and location of the job interview. ............................................................................................................................................................................................................................................................. NAME AND ADDRESS OF EMPLOYER DAYS AND HOURS WORKED [ ] B. Restricted License under Va. Code 247 46.2-391(C)(2). (Eligible only after three (3) years from the date of your last conviction.) My license was revoked based on and dependent upon three convictions pursuant to Va. Code 247 18.2-266, 247 18.2-51.4 or Subsection A of 247 46.2-341.24 or valid local ordinance or law of another state or jurisdiction relating to operating a motor vehicle under the influence of intoxicants or drugs. I represent that: (i) At the time of my convictions, I was addicted to or psychologically dependent on the use of alcohol or other drugs; and (ii) At this time I am no longer addicted to or psychologically dependent on the use of alcohol or other drugs; and (iii) At least three years have passed from the date of the last conviction upon which the revocation of my license is based; and (iv) I do not constitute a threat to the safety and welfare of myself or others with respect to the operation of a motor vehicle. I request that the Court order the issuance of a restricted license to allow me to drive to and from my home to the place of my employment, upon evaluation by the Virginia Alcohol Safety Action Program. ............................................................................................................................................................................................................................................................. NAME AND ADDRESS OF EMPLOYER DAYS AND HOURS WORKED I request that the court hold a hearing on my petition. .......................................................................................... DATE PETITIONER222S SIGNATUREFORM CC-1470 (MASTER, PAGE TWO OF TWO) 07/17 American LegalNet, Inc. www.FormsWorkFlow.com