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DRIVING PERMIT REQUEST
Risk Management Division
Phone (704) 336-3301 Fax (704) 336-7548
Please complete as much information as possible. Any field that is preceded by an "
*
" is a required field. The form cannot be submitted until all required fields are completed.
Date Submitted:
*
Reason for Request
Accident Follow-up
Applicant New Hire
Promotion
Routine Check
Other
DEPARTMENT INFORMATION
*
Department
*
Division
*
Requested By:
*
Phone Number
APPLICANT INFORMATION
*
First Name
*
Middle Name
*
Last Name
*
Current Address
*
City
/
State
/
Zip
/
/
*
SSN
*
Date of Birth
Jan
Feb
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Apr
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Oct
Nov
Dec
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*
License Number
*
State
List any other states where a License was issued in the last three years.
State
License Number
Additional Violations
List all moving violations that occurred in a state other than a state listed above. If no violations, indicate "none" below
State
Violation
Date
State
Violation
Date
State
Violation
Date
*
Are you currently waiting on Judgment for any moving violation offences not shown on your record?
No
Yes
Explain Nature of Offense(s)
*
Have your license ever been suspended or revoked for any reason?
No
Yes
List reasons and Dates
Verify that the information you have entered for this request is correct. Inform the person listed as the applicant that submitting false information concerning his/her driving record will result in revocation of their driving permit and may result in additional disciplinary actions.
I
REQUESTOR
verify that the applicant has provided the above responses for each field:
rev:03/07
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