Form

Missouri Department of Revenue

Application for Limited Driving Privilege
4595
Driver License Number Date of Birth (MM/DD/YYYY)
r205255020
0 ___
___ 2 / ___
1 ___
4 /1 9 ___
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6
Name (Last, First, Middle Initial) Social Security Number
mcwilliams
christi a 4 | 8 | 8 | 7 | 6 | 2 | 0 | 1 | 5
Street Address (Do not use P.O. Box) City, State, ZIP Code
1114 s woodland ave apt 1 independence mo 64050
Mailing Address (If different from street address) City, State, ZIP Code

E-mail Address Phone Number

mystyfyr2010@gmail.com (___
8 ___ 6 )___
1 ___ 6 ___ 2 -___
4 ___ 7 ___
2 ___
0 ___
0

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.) ____________________________________________________________________________________________
Limited Driving Privilege Reasons

____________________________________________________________________________________________________________
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.)___________________
MccKC 1775 universal ave kc mo 64120
____________________________________________________________________________________________________________

r To transport child or children to and from spousal or guardian visitation (Must provide the address.)___________________
____________________________________________________________________________________________________________

r OTHER_____________________________________________________________________________________________________
■ kids work tacobell
11020 e 23rd st indep mo 64052, waffle house 7401 ne parvin rd kc mo 64117
____________________________________________________________________________________________________________

■ To and from grocery store

r r To and from gas station
■ r To seek employment
■ To and from pharmacy
r r
■ To and from court obligations 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.

Applicant’s Signature Date of Application (MM/DD/YYYY)

Sign

0 ___
___ 8 / ___
2 ___
9 / ___ ___ ___ ___
2 0 1 8
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.
Form 4595 (Revised 02-2017)
Mail to: Driver License Bureau Phone: (573) 526-2407
Visit http://dor.mo.gov/drivers/ldp.php
P.O. Box 200 Fax: (573) 522-8795
for additional information.
Jefferson City, MO 65105-0200 E-mail: dlbmail@dor.mo.gov