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