Connecticut Form A 62 PDF Details

The Connecticut Department of Motor Vehicles (DMV) offers a Special Permit under the A-62 form that serves as a lifeline for individuals whose driving privileges have been suspended, specifically catering to those who require transportation to and from work. This crucial document, issued from the DMV’s Driver Services Division in Wethersfield, outlines a path for applicants to secure permission to drive under strict conditions, focusing on employment-related travel. With a stipulation that each application must be accompanied by a $100 non-refundable fee, it is clear that the A-62 form is a serious application for those in need. The form meticulously requires applicants to provide personal details, employment information, and a schedule that does not exceed a 12-hour window in a day, highlighting the system’s rigidity in granting such permissions. Furthermore, the possibility of operation is strictly limited to personal vehicles, as the use of vehicles requiring a Commercial Driver License (CDL) or those intended for public passenger transport remains prohibited. This indicates the program’s intention to strictly control and monitor the use of this permit. Important to the application process is the verification of the applicant’s employment status, a task that falls to the employer with detailed information and proof of work schedules, emphasizing the need for accuracy and honesty in the application. The form also addresses the necessity of public transportation alternatives, hardship considerations, and makes it clear that any misrepresentation could lead to significant legal repercussions, demonstrating the DMV’s commitment to ensuring that this permit is reserved for those who genuinely require it for employment commuting purposes.

QuestionAnswer
Form NameConnecticut Form A 62
Form Length1 pages
Fillable?Yes
Fillable fields38
Avg. time to fill out7 min 55 sec
Other namesct a 62, ct blasting permit form, ct application motor, ct application permit work

Form Preview Example

STATE OF CONNECTICUT
DEPARTMENT OF MOTOR VEHICLES
DRIVER SERVICES DIVISION
60 STATE STREET, WETHERSFIELD, CT 06161-2530
TELEPHONE: (860) 263-5720 On The Web At ct.gov/dmv

APPLICATION FOR SPECIAL PERMIT TO

OPERATE A MOTOR VEHICLE TO AND FROM WORK

A-62 REV. 4-2010

INSTRUCTIONS:

1. Please print or type.

2. Multiple employment requires separate applications.

3. A $100.00 non-refundable application fee in the form of a check or money order payable to DMV must accompany each request for a permit.

Operation of motor vehicles requiring a CDL or used for Public Passenger Transportation is PROHIBITED under the Special Permit Program

YOUR OFFICIAL DRIVING RECORD WILL BE REVIEWED AS PART OF THIS APPLICATION.

NAME OF APPLICANT (Last, First, Middle)

DATE OF BIRTH

OPERATOR LICENSE NUMBER/STATE

SEX

M

F

MAILING ADDRESS

(Number and Street)

(City or Town)

(State)

(Zip Code)

 

 

 

 

 

RESIDENCE ADDRESS (If different)

(Number and Street)

(City or Town)

(State)

(Zip Code)

NAME OF EMPLOYER (If self-employed, include business name and legal proof of self-employment)

ADDRESS OF EMPLOYER

(Number and Street)

(City or Town)

(State)

(Zip Code)

OCCUPATION

HOME TELEPHONE NUMBER

( )

DAYS AND HOURS OF EMPLOYMENT (Specify A.M. or P.M.)

TO BE ISSUED A WORK PERMIT, YOUR SCHEDULE MUST BE CLEARLY IDENTIFIED, AND

MON.

TUE.

THU.

FRI.

SAT.

MAY NOT EXCEED A CONTINUOUS 12-HOUR PERIOD PER DAY.

IF YOU HAVE MORE THAN ONE PLACE OF

EMPLOYMENT, EACH EMPLOYER MUST

WED.SUN.

COMPLETE A SEPARATE APPLICATION.

What is the distance and the commuting time from your residence to your place of employment?

Is public transportation available

 

 

 

from your residence to your

YES

NO

 

place of employment?

 

 

 

What significant hardship(s) will you suffer without a Special Operator's Permit?

 

 

What efforts have you made to obtain other transportation?

INABILITY TO CONFIRM YOUR EMPLOYMENT MAY RESULT IN DENIAL OF YOUR SPECIAL OPERATOR'S PERMIT.

PRINTED NAME OF SUPERVISOR

SIGNATURE OF SUPERVISOR

X

PRINTED JOB TITLE OF SUPERVISOR

WORK TELEPHONE

( )

NOTICE:

OATH:

Your operator's license is under suspension. If you operate any vehicle outside of the authorized hours, you may be subject to arrest. If you operate a motor vehicle for a purpose not authorized by law, a police officer may make a report to the Commissioner of Motor Vehicles and you will be subject to a civil penalty of up to $500. If your operator's license is suspended for another reason while you are in possession of this permit, the permit is revoked, and if you thereafter operate a motor vehicle you will be subject to double the penalties imposed by law. If you alter or make improper use of the permit, you will be subject to criminal penalties.

I swear or affirm under penalty of false statement in accordance with Connecticut General Statute 53a-157, and subject to penalties for perjury for a deliberate false statement, that the above information and any attachment hereto is true and correct.

PRINTED NAME OF APPLICANT

SIGNATURE OF APPLICANT

DATE SIGNED

X

DMV USE ONLY

PERMIT:

APPROVED

DENIED

DATE PERMIT ISSUED

(If Approved)

PERMIT VALID UNTIL (If Approved)

REASON FOR DENIAL

DRIVING HISTORY

NO SIGNIFICANT HARDSHIP

INELIGIBLE

OTHER (Provide Details)

AUTHORIZED SIGNATURE (DMV)

X

PRINTED NAME

DATE SIGNED

How to Edit Connecticut Form A 62 Online for Free

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In the PRINTED, JOB, TITLE, OF, SUPERVISOR SIGNATURE, OF, SUPERVISOR, X WORK, TELEPHONE NOTICE, OATH, PRINTED, NAME, OF, APPLICANT SIGNATURE, OF, APPLICANT, X D, MV, USE, ONLY DATE, SIGNED PERMIT, APPROVED, DENIED, DATE, PERMIT, ISSUED If, Approved and PERMIT, VALID, UNTIL area, jot down your information.

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