PDF Form 4595 - Application for Limited Driving Privilege
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Form
4595
Application for Limited Driving Privilege
Limited Driving Privilege Reasons
Driver License Number
Date of Birth (MM/DD/YYYY)
Name (Last, First, Middle Initial)
___ ___ / ___ ___ / ___ ___ ___ ___ Social Security Number
Street Address (Do not use P.O. Box)
| | | | | | | | City, State, ZIP Code
Mailing Address (If different from street address)
City, State, ZIP Code
E-mail Address
Phone Number
( ) - ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Applicant is requesting a limited driving privilege for the following reason(s): (Must select at least one box)
r Employment (Must provide name and address of employer(s) or if self-employed, name and address of business and type of
employment.) _______________________________________________________________________________________
___________________________________________________________________________________________________
r Education (Must provide the school(s) name and address.)_______________________________________________________
____________________________________________________________________________________________________________
r Attending a Substance Abuse Traffic Offender Program (SATOP) (Provide name and address of alcohol or drug treatment
program, if known.) ____________________________________________________________________________________________ ____________________________________________________________________________________________________________
r To and from a certified ignition interlock device (IID) service facility
r Seeking medical treatment
Being unable to operate a motor vehicle will result in a hardship to the applicant because traveling is required:
r To and from child care (Must provide child care provider(s) name and address.)____________________________________
____________________________________________________________________________________________________________
r To and from bank (Must provide the name and address of the bank.) ______________________________________________
____________________________________________________________________________________________________________
r To transport child or children to and from school(s) (Must provide the school(s) name and address.)___________________
____________________________________________________________________________________________________________
r To transport child or children to and from spousal or guardian visitation (Must provide the address.)___________________
____________________________________________________________________________________________________________
r OTHER_____________________________________________________________________________________________________
____________________________________________________________________________________________________________
r To and from grocery store r To and from pharmacy
r To and from gas station r To and from court obligations
r To seek employment r To and from church
The applicant must have proof of insurance (i.e., SR-22) on file with the Director of Revenue when submitting this application. Proof of Ignition Interlock Device (IID) service or installation must also be provided if applicable.
Sign
Applicant's Signature
Date of Application (MM/DD/YYYY)
___ ___ / ___ ___ / ____________
Mail to:
If the application is approved, an order granting the limited driving privilege will be mailed to you. You must carry the original copy of the Limited Driving Privilege Notice with you when operating a motor vehicle.
Driver License Bureau P.O. Box 200 Jefferson City, MO 65105-0200
Phone: (573) 526-2407 Fax: (573) 522-8795 E-mail: dlbmail@dor.
Form 4595 (Revised 02-2017)
Visit for additional information.
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