Dl 691 Form – Fill Out and Use This PDF

A Public Service Agency

APPLICATION FOR non-commercial RESTRICTED

DRIVER LICENSE FOR FINANCIAL RESPONSIBILITY ACTIONS

(See back for General Information and Instructions)

APPLICANT’S NAME

DRIVER LICENSE NUMBER

APPLICANT

ADDRESS

TELEPHONE NUMBER

INFORMATION

(

)

CITY

STATE

zIP CODE

Part A

I am applying for a non-commercial license restriction to drive to and from my place of employment, and/or

during my employment and the type of vehicle being operated does not require a Class A, B, or commercial

TO, FROM &

Class C license.

DURING

NOTE: (1) This restriction allows driving of any insured vehicle to and from your job, and/or on the job.

EMPLOYMENT

RESTRICTION

(2)

If you are required to drive your employer’s vehicle on the job you are not suspended when driving

(52)

a vehicle during your employment, if the vehicle is not registered to you (§16073 VC) and the type

of vehicle being operated does not require a Class A, B, or commercial Class C license.

NAME

GRADE

I am applying for a restriction to drive my minor dependent _______________________________________

from my home to school and from school to home, because no public or school bus transportation is available.

Part B

The school principal or adminisTraTor is To compleTe This porTion.

SCHOOL

I certify that, to the best of my knowledge and belief, no form of public transportation or school bus is available

TRANSPORTATION

between the applicant’s residence and this school.

FOR DEPENDENT

NAME OF SCHOOL

TELEPHONE NUMBER

MINOR

(

)

RESTRICTION

SCHOOL ADDRESS

PRIMARY

(92)

SECONDARY

CITY

STATE

zIP CODE

DATE

SIGNATURE OF PRINCIPAL OR ADMINISTRATOR

PRINTED NAME AND TITLE OF PRINCIPAL/ADMINISTRATOR

X

1. APPLICATION

I am applying for a restriction due to the following health problem requiring more than one treatment:

Part C

PATIENT’S NAME

PATIENT’S RELATIONSHIP TO DRIVER

TYPE OF HEALTH PROBLEM

(IF SELF, COMPLETE PART 2 BELOw)

MEDICAL

TREATMENT

NAME OF TREATMENT CENTER, HOSPITAL, OR MEDICAL FACILITY

RESTRICTION

ADDRESS OF TREATMENT CENTER, HOSPITAL, OR MEDICAL FACILITY

CITY

STATE

zIP CODE

For driving:

2. MEDICAL AUTHORIZATION (Complete only if you will be driving yourself to and from treatment)

(check only

I authorize my practitioner, hospital, or medical facility to release to the Department of Motor Vehicles (DMV), its

one box)

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.

Self

DATE

SIGNATURE

MEDICAL RECORD/FILE NUMBER

X

(51)

3. MEDICAL EVALUATION (Medical information is conidential per Vehicle Code §1808.5)

Family

DMV seeks the beneit of your experience and knowledge of the above named patient’s condition and the course

of treatment. This information will be used by DMV solely in evaluating the request for a restricted driver license

Member

and the restriction applicant’s ability to drive safely. Please answer all questions.

(91)

BRIEF DESCRIPTION OF HEALTH PROBLEM

TREATMENT

ExPECTED FINAL TREATMENT DATE

Both Self and

ADDRESS wHERE TREATMENTS wILL BE ADMINISTERED

Family Member

(51 & 91)

CITY

STATE

zIP CODE

IN YOUR PROFESSIONAL OPINION, wOULD APPLICANT’S CONDITION AND/OR TREATMENT BE LIkELY TO AFFECT HIS/HER DRIVING ABILITY?

No

Yes (If Yes, please explain)

DATE

PRACTITIONER’S SIGNATURE

PRACTITIONER’S PRINTED NAME

PROFESSIONAL LICENSE NO.

X

PRACTITIONER’S ADDRESS

TELEPHONE NUMBER

(

)

CITY

STATE

zIP CODE

Part D

I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

APPLICANT’S

DATE

SIGNATURE

CERTIFICATION

X

DMV USE ONLY

AUTHORIzED DMV EMPLOYEE

Refer to DS Ofice

LINE DATE/SEqUENCE

APPROVED

DENIED

DL 691 (REV. 12/2007) WWW

Vehicle Code (VC) Sections 16072, 16073, and 16077 allow for a non-commercial restricted driver license when your driving

privilege is suspended under the Financial Responsibility Law because of an uninsured accident. The restricted license is available for the irst year of the suspension, and 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:

1.Complete the Applicant Information, the parts of this application — A, B or C — that match the restriction(s) you request, and Part D. Restrictions last one year from the suspension date, and must be approved by DMV.

2.Pay a single $250 penalty fee for any or all of the restrictions. The fee is due in a single payment. NOTE: This fee is not due if you will only be driving your employer’s vehicles during your employment as a driver. See the Exemption from Suspension, below.

3.File a California Insurance Proof Certiicate (form SR 22/SR 1P), and keep it on ile for a total of four (4) years from the

suspension effective date. One year from the suspension date, the restriction(s) will end. Your unrestricted license will be valid while this Certiicate remains on ile. NOTES: (1) An SR 1P certiicate is acceptable unless another action requires the SR 22 certiicate. (2) This proof certiicate is not required if you will be driving only as permitted under the Exemption from Suspension, below.

4.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.)

exemption from suspension does noT applY to any commercial

class a, B, or commercial class c driver due to Federal regulaTions.

Except for commercial drivers (unless they downgrade to a non-commercial Class C or M license), VC Section 16073 allows persons employed as drivers to operate non-commercial vehicles not registered in their names while on the

job. This exemption from the FR suspension does not authorize driving to or from the job site. The exemption is automatic — it does not require an application, penalty fee or proof certiicate. noTe: The course of employment

restriction [Part A, over] allows driving to-and-from work as well as on-the-job.

Part A—To, From and During Employment Driving Restriction

Check the box for this restriction. 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.

Part B—School Transportation for Dependent Minor Driving Restriction

Check the box for this restriction. Complete the name and grade level of the child living in your home. The school principal or

administrator where the child is enrolled must certify that no form of public transportation or school bus is available between the home and the 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.

Part C—Medical Treatment Driving Restriction

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.

•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.

•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. 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.

NOTE: A health problem may result in suspension of your driving privilege, if DMV determines your medical condition or its treatment impairs your ability to safely operate a motor vehicle. If the department requires further evaluation of your safe driving ability, it may conduct a reexamination. You will receive notice by mail if additional medical information, or a reexamination, is necessary.

Please take this application, the $250 penalty fee, the SR 22/SR 1P insurance certiicate, and the reissue fee, if due, to your local DMV ield ofice. For faster service, please call ahead for an appointment. DMV phone numbers can be found

in the State Government section of your phone directory.

DL 691 (REV. 12/2007) WWW