Dl 691 Form – Fill Out and Use This PDF

Complete the Applicant Information, the parts of this application, A, B or C, that match the restriction(s) you request, and Part D.

Fill in APPLICANT'S NAME and DRIVER LICENSE NUMBER.

Fill in ADDRESS, TELEPHONE NUMBER, CITY, STATE and ZIP CODE.

Check the box for Part A to apply for a non-commercial license restriction to drive to and from your place of employment, and/or during your employment, when the type of vehicle being operated does not require a Class A, B, or commercial Class C license. NOTE (1): This restriction allows driving of any insured vehicle to and from your job, and/or on the job.

The restriction covers driving both to and from work and on the job, and lets you drive vehicles registered in your own name as well as other insured vehicles.

Check the box for Part B to apply for a restriction to drive your minor dependent from home to school and from school to home, because no public or school bus transportation is available.

Complete the name and grade level of the child living in your home.

The school principal or administrator is to complete this portion of Part B: the principal or administrator certifies that, to the best of their knowledge and belief, no form of public transportation or school bus is available between the applicant's residence and this school.

This restriction is available only for Kindergarten through 12th grade pupils under the age of 18.

It does not cover daycare, preschool, or after-school activities. It also does not cover the transportation of college, university or other post-high school students, regardless of age, or students driving themselves.

Check the box for the restriction requested, and the box showing whether you need to drive yourself, a family member, or both self and family to and from treatment: for driving, check only one box, Self (51), Family Member (91) or Both Self and Family Member (51 & 91).

Complete Section 1 if you are requesting a restriction to drive a family member (your spouse, child, other relative, or another person who lives with you) to and from medical treatments for a health problem requiring more than one (1) treatment appointment.

Fill in PATIENT'S NAME, PATIENT'S RELATIONSHIP TO DRIVER, TYPE OF HEALTH PROBLEM, NAME OF TREATMENT CENTER, HOSPITAL, OR MEDICAL FACILITY, ADDRESS, CITY, STATE and ZIP CODE.

Complete Section 2 if requesting a restriction to drive yourself to and from medical treatments for a health problem requiring more than one (1) treatment.

Section 2, MEDICAL AUTHORIZATION (Complete only if you will be driving yourself to and from treatment): I authorize my practitioner, hospital, or medical facility to release to the Department of Motor Vehicles (DMV), its agents, or employees information and records relating to my physical and/or mental condition, both verbally and in writing. I agree to pay for any expense involved in releasing the records.

Complete only if you will be driving yourself to and from treatment: fill in the DATE and MEDICAL RECORD/FILE NUMBER lines and sign the SIGNATURE line, which authorizes your practitioner, hospital, or medical facility to release information and records to the Department of Motor Vehicles (DMV), its agents, or employees.

Have your medical practitioner (a licensed physician; surgeon; dentist; psychiatrist; psychologist; clinical social worker; marriage, family and child counselor; or other licensed health care professional) complete Section 3.

Part D, APPLICANT'S CERTIFICATION: "I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct."

Part D, APPLICANT'S CERTIFICATION: fill in the DATE and sign on the SIGNATURE line.

Restrictions last one year from the suspension date, and must be approved by DMV.

The restricted license allows you to drive yourself or a passenger (a child under age 18 or other members of your household, depending on the restriction requested) when you meet the following requirements. File a California Insurance Proof (form SR 22/SR 1P), and keep it on file for a total of four (4) years from the suspension effective date. Take this application, the $250 penalty fee, the SR 22/SR 1P insurance, and the reissue fee, if due, to your local DMV (checked October 31, 2026).

Pay a single $250 penalty fee for any or all of the restrictions. The fee is due in a single payment (checked October 31, 2026). This fee is not due if you will only be driving your employer's vehicles during your employment as a driver. Pay a reissue fee, if due. The fee is not due on the Financial Responsibility [FR] suspension if the restriction application is completed and approved before the suspension starts.