South Carolina Department of Motor Vehicles



SECTION 1 – JUDGE’S NAME | |

|By order of the Honorable |      |, the minor |

| |(print) | |

listed on this form shall have his/her driving privilege to operate a motor vehicle in the State of South Carolina

restricted in the manner described below:

|SECTION 2 - MINOR’S INFORMATION |

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|Name: |      |

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|Address: |      |

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|City: |      |State: |      |Zip Code: |      |

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|Credential Number: |      |Date of Birth: |      |

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|Parent(s), Guardian or Custodian: |      |

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|Address: |      |

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|City: |      |State: |      |Zip Code: |      |

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|SECTION 3 - RESTRICTION INFORMATION |

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|SC Code of Law §16-17-500 (E)-(4) Tobacco Restriction- Minor |

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|Effective Date of Restriction: |      |

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|Termination Date of Restriction: |      |

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| |1. Driving privileges are restricted to driving to and from school. |

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| |2. Driving privileges are restricted to driving to and from work. |

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| |3. Driving privileges are restricted to driving to and from church. |

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| |4. Driving privileges are restricted, as the court considers appropriate (additional instructions below). |

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| |5. Minor is not licensed and the issuance of a driver’s license or beginner’s permit is delayed for 90 days after making application for a |

| |credential or until the minor’s 18th birthday. |

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|Additional Instructions: |      |

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|SECTION 4 – COURT INFORMATION |

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|Date: |      | |Judge’s Signature: | |

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|Court Name: |      |

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|Court Address: |      |

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