DMV DL 120 Form – Fill Out and Use This PDF

JUNIOR PERMIT STATEMENT OF FACTS

120

A Public Service Agency	(SECTIONS 12513, 12514 C.V.C.)

COMPLETED application must be submitted in person to the local office of the Department of Motor Vehicles. Attach separate sheet if more space is needed. Incomplete information may delay decision. An Application for a Noncommercial Driver License/Identifi- cation Card (DL 44) must be submitted with this form.

Permit can only be approved if certain HARDSHIP conditions are shown to exist. ALL other transportation must be inadequate. Applicant must be at least 14, but under 18 years of age.

STATEMENT OF FACTS BY PARENTS

CHECK ONE OR MORE OF THE FOLLOWING

I.	Illness	II.	School	III.	To and From Work			IV.		Family Enterprise
APPLICANT'S FULL NAME				DATE OF BIRTH		HOME PHONE			DAY PHONE (if different)
						(	)		(	)
STREET ADDRESS						CITY			ZIP CODE

IF PRIOR JUNIOR PERMIT APPLICATION MADE FOR APPLICANT OR OTHER FAMILY MEMBER, GIVE NAME AND YEAR

ESTABLISH THAT TRANSPORTATION IS INADEQUATE

DESCRIBE APPLICANT'S ESSENTIAL DRIVING NEEDS

DISTANCE FROM APPLICANT'S RESIDENCE TO NEAREST PUBLIC TRANSPORTATION	LOCATION BY STREETS OF NEAREST BUS OR TRAIN STOP

DESCRIBE BEST BUS OR TRAIN ROUTE, GIVE NAME OF SERVICE, TELEPHONE NUMBER, NAME OR NUMBER OF INDIVIDUAL LINE(S), DEPARTURE, TRANSFER AND ARRIVAL TIMES, ETC.

LIST NAMES AND DRIVER LICENSE NUMBERS OF ALL DRIVERS IN THE HOUSEHOLD

EXPLAIN SPECIFICALLY WHY EACH DRIVER IN THE HOUSEHOLD CANNOT DO THE REQUIRED DRIVING. INCLUDE DAILY WORK OR SCHOOL AND TRAVEL SCHEDULE OF EACH DRIVER, NATURE AND LOCATION OF EMPLOYMENT AND DISTANCE FROM HOME AND APPLICANT'S SCHOOL. INCLUDE NUMBER OF EMPLOYEES, IF SELF-EMPLOYED

IF HOUSEHOLD INCLUDES NON-DRIVING ADULT OR MINOR OLDER THAN APPLICANT, GIVE NAME AND RELATIONSHIP TO APPLICANT AND EXPLAIN WHY PERSON CANNOT/DOES NOT DRIVE. (If medical reason, separate Statement of Facts by Physician needed.)

EXPLAIN WHY CARPOOLS, TAXIS, BICYCLES, WALKING, VANPOOLS, ETC. CANNOT BE USED

DRIVER EDUCATION AND TRAINING

HAS APPLICANT COMPLETED APPROVED DRIVER EDUCATION AND TRAINING COURSES? (If no, reason.)

Yes No

IF A JUNIOR PERMIT IS ISSUED, CERTIFICATES OF COMPLETION OF DRIVER EDUCATION AND TRAINING MUST BE ON FILE WITHIN SIX MONTHS OR THE PERMIT MUST BE CANCELLED. DESCRIBE PLAN TO COMPLETE COURSES IF PERMIT IS ISSUED.

I. ADDITIONAL INFORMATION REQUIRED IF REQUEST IS DUE TO FAMILY ILLNESS

ESTABLISH THE RELATIONSHIP BETWEEN THE ILL PERSON AND THE APPLICANT	INDICATE WHETHER OR NOT THE PERSON'S ILLNESS PREVENTS THEM DRIVING AND FOR HOW LONG
	Yes	No	If yes, how long?

II. ADDITIONAL INFORMATION REQUIRED IF REQUEST IS BASED ON NEED FOR TRANSPORTATION TO AND FROM SCHOOL

DESCRIBE TRANSPORTATION ARRANGEMENTS TO DATE

EXPLAIN THE CHANGE IN CIRCUMSTANCES THAT NOW MAKES THE APPLICANT'S OPERATION OF A MOTOR VEHICLE ESSENTIAL

III. ADDITIONAL INFORMATION REQUIRED IF REQUEST IS BASED ON NEED FOR TRANSPORTATION TO AND FROM WORK

EXPLAIN CHANGES IN FAMILY CIRCUMSTANCES THAT NOW MAKE APPLICANT'S INCOME ESSENTIAL IN THE SUPPORT OF THE FAMILY

APPLICANT'S NET OR TAKE HOME INCOME

DESCRIBE USE OF APPLICANT'S INCOME

$PER

ALL OTHER SOURCES OF FAMILY'S INCOME

IV. ADDITIONAL INFORMATION REQUIRED IF REQUEST IS BASED ON FAMILY ENTERPRISE

NAME AND ADDRESS OF ENTERPRISE

NATURE AND TYPE OF ENTERPRISE	YEARS IN BUSINESS	NO. OF EMPLOYEES (include family members)

EXPLAIN SPECIFICALLY WHY EACH EMPLOYEE CANNOT DO THE REQUESTED DRIVING. INCLUDE DAILY WORK AND TRAVEL SCHEDULE OF EACH EMPLOYEE

DL 120 (REV. 9/91) WWW	Continue on reverse

Name ____________________________________ DOB _____________________

NAME OF EMPLOYEE

DATE OF EMPLOYMENT

SALARY

$PER

DISTANCE FROM APPLICANT'S RESIDENCE TO PLACE OF EMPLOYMENT

DISTANCE FROM PLACE OF EMPLOYMENT TO PUBLIC TRANSPORTATION

CERTIFICATION TO BE COMPLETED BY:

Physician

School Principal

Employer

NAME OF SIGNER (print or type)

TITLE