Dmv 21 Form PDF Details

Driving is a privilege that comes with responsibilities, and at times, due to various reasons, that privilege can be limited or suspended. The DMV 21 form, also known as the Application for Restricted License, comes into play for individuals seeking to regain some driving abilities under specific conditions. This form serves various groups including juveniles in rural areas needing transportation for education or medical reasons, and adults who have faced license suspension or revocation but require a vehicle to go to work, attend medical appointments, or fulfill court-ordered obligations. The application process outlined in the form is meticulous, requiring detailed personal information, the reason for requesting the restricted license, and verification from third parties like employers or medical practitioners. Moreover, it underscores the importance of insurance through the SR-22 requirement and highlights possible testing and fees. Additionally, it addresses the use of an ignition interlock device as a condition for some applicants. The DMV 21 form is a critical step for those in Nevada seeking to navigate life with limited driving privileges, emphasizing the need for adherence to rules and verification of the necessity for such a license. As each section of the form addresses different needs and stipulations, it becomes clear that obtaining a restricted license is a process that demands thorough documentation and proof of specific qualifying conditions.

QuestionAnswer
Form NameDmv 21 Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesdmv021 dmv nevada phone number form

Form Preview Example

Field Services Division

Reno/Carson City 684-4DMV

Las Vegas 486-4DMV

Rural NV (877) 368-7828

www.dmvnv.com

RESTRICTED LICENSE INFORMATION

A restricted license may be obtained for a variety of reasons.

Juveniles in certain rural areas who need to drive in order to attend school or to transport themselves or a family member to medical appointments may apply for a restricted license.

Individuals who have had their license suspended or revoked and have served at least half of their withdrawal period may apply for a restricted license to drive on the job or to/from work, school, grocery store, medical appointments or for court-ordered child visitation.

Exceptions apply for ignition interlock requirements, child support suspensions and some juvenile suspensions. Please call the appropriate phone number above for the address of a DMV Restricted License office near you.

APPLICATION: A restricted license cannot be approved for commercial driving purposes, to seek employment, or for public school students in Carson City, Clark, Douglas or Washoe Counties.

Complete all sections of the Application for Restricted License that pertain to you. Attach all required documents.

Drive to/from work or drive on the job: Your employer must complete certain information on the application. Self- employed applicants must attach a copy of their business license or other acceptable document(s) to substantiate self-employment. Workdays and hours are limited to a maximum of six (6) days per week, ten (10) hours per day.

Drive for medical purposes: A physician’s statement is required.

Drive to/from medical appointments or a grocery store: The “Verification of Need” affidavit must be completed by an unbiased individual and signed in front of a DMV authorized representative.

Minor drive to/from school or work: School authorities and parents/guardians must complete certain sections.

SR-22: Proof of financial responsibility (SR-22 Certificate of Insurance) must be filed after any revocation and certain suspensions before a restricted license will be issued. The SR-22 insurance must be in place for a continuous three (3) year period from the date your driving privilege is reinstated.

TESTING & FEES: Applicants may be required to successfully complete written, vision, and drive examinations before a restricted license is issued. A reinstatement fee may be required.

IGNITION INTERLOCK DEVICE: If you have been ordered to install an ignition interlock device on your vehicle, proof of that installation must be submitted with your application for a restricted license. Nevada law requires that an applicant wait 45 days after a 1st DUI and one (1) year after a 3rd DUI before applying for a restricted license. A restricted license is prohibited by law after a 2nd DUI.

POINT VIOLATOR SUSPENSION: Per NAC 483.225, proof of completion or enrollment in an approved traffic safety course within the past 6 months is required for individuals whose license was suspended due to an accumulation of demerit points as outined in NRS 483.475.

DENIAL OF AN APPLICATION: A restricted license application will be denied if your license was suspended or revoked for any of the following:

1.A financial responsibility, medical or failure to appear suspension

2.Certain driving record convictions within the past five (5) years

3.The third demerit point suspension within the past five (5) years

DMV-136 (Rev. 02/2010)

Field Services Division

Reno/Carson City 684-4DMV

Las Vegas 486-4DMV

Rural NV (877) 368-7828

www.dmvnv.com

APPLICATION FOR RESTRICTED LICENSE

INSTRUCTIONS: Please type or print in BLACK ink. Failure to complete all applicable sections will cause considerable delay in processing your application. You will be notified by mail of your approval or denial and provided instructions on how to pick up your license. Bring, mail or fax this completed application to the DMV Restricted License office in your area:

 

Northern Nevada

305 Galletti Way, Reno NV 89512

Fax: (775) 684-3587

 

 

Southern Nevada

1399 American Pacific Drive, Henderson NV 89074

Fax: (702) 486-1300

 

REQUEST TO DRIVE:

To/from work

To/from school

For medical purposes

 

 

On the job for work-related purposes

To/from grocery store

APPLICANT INFORMATION

Name _____________________________________________________________________________ Home Phone __________________________

LastFirstMiddle

Residence Address ___________________________________________________________________ City/Zip _______________________________

Mailing Address (if different) ____________________________________________________________ City/Zip _______________________________

County_______________ Driver’s License # ______________________ Social Security #_____________________Date of Birth _______________

Does a licensed driver (not applicant) reside in the household?

Yes

No If “Yes,” name: ________________________________________

Relationship to Applicant_________________________________________ Driver’s license number____________________________________

(Effective 7/1/2010) If you are a male at least 18 and less than 26 years of age, would you like to register with the Selective Service? By registering, you will remain eligible for federal student loans, grants, benefits relating to job training, most federal jobs and, if applicable, citizenship in the United States. If YES, please initial here: _______________

SECTION A: DRIVE TO/FROM WORK; DRIVE ON THE JOB FOR WORK-RELATED PURPOSES

This license is effective only for employment designated on this application.

Most direct route from home to work__________________________________________________________________________________________

Exact # miles from your home to work, via most direct route _________________________

Are you self-employed?

Yes

No

If “Yes,” provide a copy of your business license or other substantial proof.

EMPLOYERS AND SELF-EMPLOYED APPLICANTS COMPLETE THE FOLLOWING:

Business name___________________________________________________________ Phone__________________________________________

Business address/city/zip __________________________________________________________________________________________________

Days Applicant works______________________________________________________ Exact hours: ____________am/pm to_____________am/pm

Applicant required to drive during work hours?

Yes

No

If so, specify areas where applicant must drive (city, work yard, etc.)

_______________________________________________________________________________________________________________________

VERIFICATION OF EMPLOYMENT (TO BE COMPLETED BY EMPLOYER)

I AM AUTHORIZED TO PROVIDE THE INFORMATION INDICATED ABOVE AND VERIFY THAT THE APPLICANT IS CURRENTLY EMPLOYED WITH THIS BUSINESS. I FURTHER CERTIFY THAT I WILL NOTIFY THE NEVADA DMV IF THIS EMPLOYEE TERMINATES EMPLOYMENT.

Signature of Applicant’s Superior_____________________________________________________________________ Date___________________

Print Name/Title__________________________________________________________________________________________________________

DMV-21 (Rev. 02/10)

SECTION B: DRIVE TO/FROM GROCERY STORE

Name of grocery store____________________________________ Address_________________________________________________________

Most direct route from home to store_________________________________________________________________________________________

Exact # miles from your home to store, via most direct route _________________________

Specify 2 days per week for travel: (1)_________________ (2)_________________________ Two hours: _________ am/pm to ___________am/pm

“Verification of Need” must be completed - see Section F, “AFFIDAVITS, VERIFICATIONS”

SECTION C: DRIVE TO/FROM MEDICAL APPOINTMENTS - MEDICAL HARDSHIP IN FAMILY

Name of household member with medical condition________________________________________ Person’s Social Security #_________________

Nature of medical condition_________________________________________________________________________________________________

Name of medical provider________________________________________________Phone #____________________________________________

Address of medical provider_________________________________________________________________________________________________

Most direct route from home to medical provider___________________________________________________________________________________

Exact # miles from your home to medical provider, via most direct route _________________________

Dates of medical appointments______________________________________ Time_________________ am/pm (Attach additional sheets if necessary)

Attach statement from medical provider, on provider’s letterhead and dated within the past thirty (30) days. Must include (1) description of medical condition, (2) prescribed medications, (3) verification that medical condition renders person unable to operate a motor vehicle, (4) whether medical condition is temporary or permanent, (5) if temporary, estimated time for recovery, (6) any recommended restrictions. (NAC 483.266)

“Verification of Need” must be completed - see Section F, “AFFIDAVITS, VERIFICATIONS”

SECTION D: DRIVE TO/FROM SCHOOL

Per NRS 483.270, public school students from Carson City, Clark, Douglas and Washoe Counties are not eligible for a to/from school restricted license.

STUDENTS AGE 14-18: This license shall be issued for the current school year only and used exclusively for academic purposes, NOT extracurricular activities. The route shall be travelled on scheduled school days only, no more than once daily. Do not exceed posted speed limits.

If minor’s license was revoked or suspended under NRS 62, “Juvenile Justice,” attach certified copy of court order authorizing restricted driving privileges to and from school and/or work.

If minor is employed and needs to drive to/from work, also complete Section A of this form.

If home is less than 2 miles from school and student cannot walk, must submit physician statement meeting criteria of NAC 483.267.

Why is it impossible or impractical to provide transportation for this student? _________________________________________________________

______________________________________________________________________________________________________________________

Most direct route from home to school________________________________________________________________________________________

Exact # miles from your home to school, via most direct route _________________________

Specify days of week for travel _____________________________________________________ Hours: _________ am/pm to ___________am/pm

SCHOOL VERIFICATION (TO BE COMPLETED BY SCHOOL AUTHORITY)

Name of School_________________________________________________________________ Phone___________________________________

Address ________________________________________________________________________________________________________________

1.

Is the student’s enrollment in this school based on an approved variance?

Yes

No

 

 

2.

Does the school provide bus transportation or transportation for hire to the student’s residential area?

Yes

No

3.

Dates of school semesters: (1st) Begins____________ Ends_____________

(2nd) Begins____________

Ends______________

4.

Exact hours student attends school (exclude extracurricular activities)

From __________________ am/pm to ___________________am/pm

THE UNDERSIGNED ATTESTS THAT THE INFORMATION PROVIDED IS ACCURATE ACCORDING TO SCHOOL RECORDS.

Signature ______________________________________________________________________________________ Date____________________

Print Name/Title__________________________________________________________________________________________________________

SECTION E: DRIVE TO/FROM COURT-ORDERED CHILD VISITATION

Address where child(ren) reside, including city__________________________________________________________________________________

Most direct route from home to school________________________________________________________________________________________

Exact # miles from your home to child’s residence, via most direct route _________________________

Specify days of week for travel _____________________________________________________ Hours: _________ am/pm to ___________am/pm

Attach certified copy of court order authorizing restricted driving privileges to and from child visitation (NAC 483.252).

SECTION F: AFFIDAVITS, VERIFICATIONS

A Notary Public may verify any of the below signatures in place of a DMV representative (Notary statement and seal must be attached).

VERIFICATION OF NEED. This verification must be completed by an unbiased person (neighbor, social worker, clergyman) not residing in the household and be signed before a person authorized to administer oaths (NRS 483.300).

Print name_________________________________________________________________________ Phone_______________________________

Address/city/zip__________________________________________________________________________________________________________

Relationship to applicant_________________________________

Explain applicant’s inability to obtain other method of transportation___________________________________________________________________

Describe applicant’s or family member’s medical problems (if applicable) ________________________________________________________________

Signature___________________________________________________________________________ Date________________________________

Authorized DMV Representative_____________________________________ Print Name_______________________________________________

APPLICANT AFFIDAVIT (TO BE SIGNED BY ALL APPLICANTS)

I UNDERSTAND THAT MY RESTRICTED LICENSE WILL BE CANCELLED BY THE DEPARTMENT IF:

1.I am convicted of a traffic violation which is assigned 4 or more demerit points.

2.My driving privilege is suspended, revoked or cancelled for any reason other than the reason I am applying for this license.

3.I fail to maintain proof of financial responsibility as required by NRS 485.307.

4.I fail to notify the DMV in writing whenever I change my address, employment or any other information included in this application within 10 days after the change occurs. I understand this change must be submitted to the same office where I am applying for this license. (NRS 483.240)

5.I fail to submit proof of completion or enrollment in an approved traffic safety school if required by NAC 483.225.

I CERTIFY UNDER PENALTY OF PERJURY THAT ALL STATEMENTS MADE ON THIS APPLICATION ARE TRUE AND CORRECT. I UNDERSTAND THAT ANY MISSTATEMENT MAY CAUSE DENIAL AND/OR CANCELLATION OF MY RESTRICTED LICENSE, AND THAT FAILURE TO COMPLY WITH RESTRICTIONS OR ANY CONDITIONS OF THE RESTRICTED LICENSE MAY RESULT IN CANCELLATION OF THIS PRIVILEGE.

Applicant Signature____________________________________________________________________ Date______________________________

Authorized DMV Representative_____________________________________ Print Name_______________________________________________

PARENT/GUARDIAN AFFIDAVIT (TO BE COMPLETED AND SIGNED BY PARENT OR GUARDIAN OF MINOR APPLICANT) Father’s/Guardian’s name______________________________________________________ Driver’s License #___________________________

Address______________________________________________________________________ Home Phone______________________________

Employer’s name/address_________________________________________________________________________________________________

Work days/hours_______________________________________________________________ Work Phone_______________________________

Mother’s/Guardian’s name______________________________________________________ Driver’s License #__________________________

Address______________________________________________________________________ Home Phone______________________________

Employer’s name/address_________________________________________________________________________________________________

Work days/hours_______________________________________________________________ Work Phone_______________________________

I CERTIFY THAT I AM THE PARENT OR GUARDIAN OF THE APPLICANT AND THAT ALL STATEMENTS MADE ON THIS APPLICATION ARE CORRECT. I UNDERSTAND THAT ANY MISSTATEMENT MAY CAUSE DENIAL AND/OR CANCELLATION OF THE LICENSE. I ACCEPT LIABILITY FOR ANY NEGLECT OR WILLFUL MISCONDUCT BY THE MINOR AND AGREE THAT FAILURE OF THE MINOR TO COMPLY WITH RESTRICTIONS OR ANY CONDITIONS OF THE RESTRICTED LICENSE MAY RESULT IN CANCELLATION OF THIS PRIVILEGE.

Parent/Guardian Signature_______________________________________________________________ Date______________________________

Authorized DMV Representative_____________________________________ Print Name_______________________________________________

FOR DEPARTMENT USE:

Verified ___________________________________________________

Date ____________________

SR-22:

Needed

Filed

No

Traffic Safety School:

Yes

No

PDPS:

No Match

LIC

ELG

NOT State ________ Number ___________________________________

Approved

Denied

Reason Denied ___________________________________________________________________________

Eligibility Date ________________ Expiration Date _________________ Restricted License No. __________________________________________

DMV-21 (02/2010)

How to Edit Dmv 21 Form Online for Free

Dmv 21 Form can be completed online with ease. Simply make use of FormsPal PDF editor to complete the job in a timely fashion. The editor is constantly upgraded by us, receiving new functions and growing to be greater. If you are looking to get started, this is what it's going to take:

Step 1: Access the PDF doc inside our tool by pressing the "Get Form Button" above on this page.

Step 2: The tool enables you to customize PDF files in a variety of ways. Enhance it by adding any text, adjust what is originally in the file, and put in a signature - all readily available!

To be able to fill out this PDF form, make sure that you type in the required information in each blank:

1. While filling in the Dmv 21 Form, ensure to complete all of the important blank fields within its relevant area. This will help facilitate the work, which allows your details to be processed without delay and properly.

Stage number 1 of submitting Dmv 21 Form

2. After finishing the previous part, go to the subsequent part and enter the necessary details in all these blanks - This license is effective only for, Yes, If Yes provide a copy of your, Most direct route from home to, If so specify areas where, and Yes.

Filling in section 2 of Dmv 21 Form

3. This 3rd segment should also be fairly uncomplicated, SECTION B DRIVE TOFROM GROCERY, Name of grocery store Address Most, Verification of Need must be, Name of household member with, cid SECTION D DRIVE TOFROM SCHOOL, and Per NRS public school students - every one of these form fields will have to be filled out here.

Stage number 3 for filling out Dmv 21 Form

4. Your next subsection will require your information in the subsequent parts: If minors license was revoked or, cid cid Why is it impossible or, Most direct route from home to, Is the students enrollment in this, From ampm to ampm, nd Begins Ends, Yes, Yes, and Signature Date Print NameTitle. Be sure that you fill in all needed details to go further.

nd Begins Ends, If minors license was revoked or, and Signature  Date Print NameTitle inside Dmv 21 Form

5. Because you draw near to the finalization of your file, you'll notice several more points to undertake. In particular, Signature Date Print NameTitle, and Address where children reside must all be filled out.

Dmv 21 Form writing process outlined (part 5)

Lots of people often make errors while completing Signature Date Print NameTitle in this section. Ensure you read twice what you enter here.

Step 3: Check all the information you have entered into the blank fields and then click on the "Done" button. After setting up a7-day free trial account with us, it will be possible to download Dmv 21 Form or email it right away. The PDF form will also be readily accessible in your personal cabinet with your each and every change. FormsPal is committed to the confidentiality of all our users; we ensure that all information processed by our system is protected.