Fill Out a Valid Mv3027 Wisconsin Template Edit Form Online

Fill Out a Valid Mv3027 Wisconsin Template

The Mv3027 Wisconsin form is an application for an Occupational Operator License, allowing individuals with suspended or revoked driving privileges to drive for essential purposes. To qualify, applicants must complete the necessary tests, provide proof of identity, and submit an SR22 insurance certificate, among other requirements. If you need to fill out this form, click the button below to get started.

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The MV3027 form is a crucial document for individuals seeking an Occupational Operator License in Wisconsin. This license allows those with suspended or revoked driving privileges to legally operate a vehicle for essential purposes related to their employment, education, or necessary personal activities. To apply, applicants must complete the MV3001 form alongside the MV3027, ensuring they meet specific requirements. These include passing a vision screening, providing proof of identity, and submitting an SR22 insurance certificate. A nonrefundable fee of $50 is also required. For those under 18, a notarized sponsor signature is mandatory. The application must detail the applicant's occupation, driving needs, and the counties or states where driving will occur. Additionally, individuals with multiple OWI convictions must comply with Driver Safety regulations, which may involve assessments and participation in a Driver Safety Plan. The form outlines precise instructions for completion, including how to list driving times and purposes accurately. Understanding the MV3027 is essential for navigating the process of obtaining an Occupational Operator License in Wisconsin.

Listed Questions and Answers

  1. What is the MV3027 form?

    The MV3027 form, also known as the Application for Occupational Operator License, is a document used in Wisconsin for individuals who have had their driving privileges suspended or revoked. This form allows them to apply for a limited driving license, which can be used for specific purposes such as work, school, or essential errands.

  2. Who is eligible to apply for the Occupational Operator License?

    To qualify for an Occupational Operator License, you must have a suspended or revoked driving status. Additionally, if you are under 18 years old, a notarized sponsor signature is required. Individuals with multiple OWI convictions must also comply with Driver Safety regulations, which include submitting to an alcohol or drug assessment.

  3. What documents do I need to submit with the MV3027 form?

    You will need to submit several documents along with your completed MV3027 form, including:

    • A completed Wisconsin Operator License Application (MV3001).
    • Proof of identity, such as a Wisconsin Driver License or ID card, or a signed original Social Security Card.
    • An SR22 insurance certificate.
    • A $50 nonrefundable fee.
  4. How do I fill out the application correctly?

    When completing the MV3027 form, it is essential to fill in all required fields clearly. Include your name, birth date, driver license number, and contact information. List your occupation and employer, check all necessary uses for the license, and specify the counties or states where you need to drive. Additionally, you must provide the actual driving times you require for your activities, ensuring that they are within the allowed limits.

  5. What are the restrictions on the Occupational Operator License?

    The Occupational Operator License is not intended for recreational driving or operating commercial vehicles. The license can only be used during the specified times and for the purposes outlined in your application. Be mindful that if you have been ordered to have an Ignition Interlock Device (IID), it must be installed in all vehicles registered to you unless exempted by the court.

  6. What happens if I do not comply with the terms of my Occupational License?

    If you fail to comply with the terms of your Occupational Operator License, you may face further legal consequences, including additional penalties or a longer suspension of your driving privileges. It is crucial to adhere to the driving times and purposes specified in your application.

  7. Where can I find more information or assistance regarding the MV3027 form?

    For more information about the MV3027 form and the Occupational Operator License, you can visit the Wisconsin DMV website at wisconsindmv.gov/occupational. If you have specific questions, you can also call the DMV at (608) 264-7447 or email them for assistance.

Key takeaways

When filling out and using the MV3027 form for an Occupational Operator License in Wisconsin, there are several important points to keep in mind:

  • Eligibility Requirements: To qualify for this license, you must have a suspended or revoked driving status. Ensure you check your eligibility on the Wisconsin DMV website or call their office.
  • Necessary Documentation: You will need to complete the MV3001 application alongside the MV3027. Additionally, provide proof of identity, an SR22 insurance certificate, and, if applicable, evidence of compliance with Driver Safety regulations.
  • Accurate Driving Times: When listing your driving times, be specific. Include only the hours you will be driving, not the hours you will be working. Remember to use the correct format for start and stop times.
  • Define Your Driving Areas: Clearly list all counties or states where you need to drive, including your county of residence. Avoid vague descriptions; be precise to ensure your application is accepted.
  • Signature and Certification: By signing the application, you confirm that the information provided is accurate and that you will only drive during the specified times and locations necessary for your occupation.
  • Nonrefundable Fee: Be prepared to pay a $50 nonrefundable fee when submitting your application. Ensure you have this amount ready to avoid delays in processing.

Completing the MV3027 form accurately and thoroughly is essential for obtaining your Occupational Operator License. Take your time to gather all required information and documentation before you begin the application process.

Document Overview

Fact Name Details
Purpose of MV3027 The MV3027 form is used to apply for an Occupational Operator License in Wisconsin, allowing individuals with a suspended or revoked driving status to drive for specific occupational purposes.
Eligibility Requirements Applicants must have a suspended or revoked driving status, complete necessary tests, and provide proof of identity, among other requirements, to qualify for the license.
Application Fee A nonrefundable fee of $50 must be paid when submitting the MV3027 application.
Governing Laws The issuance of the Occupational Operator License is governed by Wisconsin Statutes §343.10 and §343.305, which outline the conditions and procedures for obtaining such a license.
Restrictions on Use The Occupational License cannot be used for recreational driving or for operating a commercial motor vehicle, ensuring it serves strictly occupational needs.

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Misconceptions

  • Misconception 1: Anyone can apply for an Occupational Operator License.
  • This is incorrect. To qualify for this license, an individual must have a suspended or revoked driving status. Without this specific condition, the application will not be accepted.

  • Misconception 2: The Occupational Operator License can be used for any type of driving.
  • This is misleading. The license is strictly for occupational purposes and cannot be used for recreational driving. For example, driving for pleasure or leisure activities is not permitted under this license.

  • Misconception 3: A notarized sponsor signature is required for all applicants.
  • This requirement only applies to applicants under the age of 18. Those who are 18 or older do not need a notarized signature, simplifying the process for adult applicants.

  • Misconception 4: Completing the application is the only step in obtaining the license.
  • This is not the case. Applicants must also complete necessary tests, such as a vision screening, and provide proof of identity and insurance. These steps are essential for a successful application.

  • Misconception 5: There are no restrictions on the hours of driving allowed with this license.
  • This is false. The application requires applicants to specify their actual driving times. It is important to adhere to these listed times, as driving outside of them is not permitted.

  • Misconception 6: If an applicant has multiple OWI convictions, they can easily obtain the license.
  • This is a misconception. Applicants with two or more OWI convictions must comply with additional regulations, including submitting to an alcohol or drug assessment and participating in a Driver Safety Plan.

Form Sample

APPLICATION FOR OCCUPATIONAL OPERATOR LICENSE – INSTRUCTIONS

Wisconsin Department of Transportation

MV3027 11/2018

ITEMS NEEDED TO APPLY

Complete a Wisconsin Operator License Application MV3001 and the attached Occupational Operator License Application MV3027.

If you are under 18 years old, a notarized sponsor signature is required.

Complete necessary tests, including vision screening.

Provide proof of your identity, such as a Wisconsin Driver License or ID card or a signed original Social Security Card.

Provide an SR22 insurance certificate.

You must have a suspended or revoked driving status to qualify for an Occupational Driver License. Please go to wisconsindmv.gov/occupational to check your eligibility for an Occupational License or call (608) 264-7447.

Pay a $50 nonrefundable fee.

If you have two or more OWI convictions and are currently revoked for OWI, you must be in compliance with Driver Safety regulations by submitting to an alcohol or other drug assessment and participating in a Driver Safety Plan. For more information please call (608) 261-8202.

If the court has ordered an Ignition Interlock Device (IID) restriction, IIDs must be installed in all vehicles titled or registered to the applicant, unless the vehicle has been exempted by the court.

If you have been revoked as a Habitual Traffic Offender (HTO), the circuit court in your county of residence must approve the issuance of your occupational license.

INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR OCCUPATIONAL LICENSE MV3027. (print clearly)

1.Fill in your name, birth date, driver license number, and telephone number.

2.List your occupation(s) and the name(s) of your employer(s). Self employed person(s) provide business name(s).

3.Check the appropriate boxes for ALL the uses you need for the occupational license. If you are a student, indicate the school you are attending. Homemaker may include, but is not limited to: grocery shopping, medical appointments, caring for parent or spouse, taking children to school activities, child visitation, etc. Homemaker does NOT include operation for pleasure or recreation. An occupational license cannot be used for driving a commercial motor vehicle.

If you have been convicted of Operating While Intoxicated (OWI), you must complete an alcohol assessment. You will also be required to complete a Driver Safety Plan. If you are currently enrolled in a Driver Safety Plan, check the yes box and include the time you will need to drive to attend your sessions. If you have completed or have not yet enrolled in a Driver Safety Plan, check the no box.

4.List the counties or states in which you need to drive. This list must include your county of residence. Be sure to consider

ALL areas where you need to drive. For example, if you live in Madison and must travel to Green Bay for work, be sure to list ALL counties you will be driving through to get to Green Bay. You must be able to define the areas where you will be driving. A statement like Southern Wisconsin is unacceptable because the area cannot be specifically defined.

5.List your actual driving time only. This should include only the time you will be operating a vehicle. Be sure to give yourself enough time to go to and from your destination. You can legally drive only during the times you list. Do not list the hours you will be working unless you need to drive while you work.

When listing the time you will be driving, indicate A for AM, P for PM, N for Noon and M for Midnight. Start and Stop times must end in either :00, :15, :30 or :45. For example, if it takes you 35 minutes to go to your place of employment and you start at 10:00 a.m., list your Start as 9:15 a.m. and your Stop as 10:00 a.m. Do NOT list hours starting on one day and ending on the next. Example: If you need to drive 10 p.m. - 2 a.m. on Saturday, list your hours as 10 p.m. – 12 midnight on Saturday and 12 midnight to 2 a.m. on Sunday. Do NOT exceed 12 hours for any one day and 60 hours for the entire week.

6.Total the amount of time you will be driving for each day and for the entire week.

7.Sign and date the application. By signing the application, you are certifying that you are operating a motor vehicle, during the times and at the locations specified in the application, as necessary for fulfilling the duties of your occupation.

A sample of a completed application MV3027 is on the reverse side.

For additional information, see the Occupational License Information publication BDS361

or visit the Wisconsin DMV website wisconsindmv.gov.

For specific questions, please call (608) 264-7447 or email wisconsindmv.gov/email.

APPLICATION FOR OCCUPATIONAL OPERATOR LICENSE

Wisconsin Department of Transportation

 

MV3027

11/2018

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(1) Applicant Name (First, Middle Initial, Last)

 

 

 

Birth Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Driver License Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Daytime Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Julie

M. Citizen

 

 

 

 

 

 

 

 

0

1

 

 

 

 

0

 

7

 

 

 

1

9

8

 

0

 

 

C

 

1

2

3

 

 

 

 

1

 

2

3

4

 

 

 

 

1

2

3

 

4

 

 

 

 

0

1

 

(608) 123-1234

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

M

 

 

D

D

Y

Y

Y

 

Y

1

 

2

3 4

5

6

7 8

 

 

9 1 0 11 12

 

 

13 14

 

 

 

 

 

 

 

(2) OCCUPATION

 

 

EMPLOYER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(3) Occupational License Uses (Check ALL Necessary)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ü Church

 

 

 

 

 

 

 

 

 

 

 

 

 

Emergency Service Provider

 

 

 

 

Clerk

 

 

 

 

 

Gas, Inc.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ü Homemaker

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Groomer

 

 

 

 

K9 Grooming (self-employed)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Student at:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have You Enrolled in a Driver Safety Plan

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

ü No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(4) List ALL Counties or States in which you will be driving (Include your County of Residence)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dane, Columbia

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If Yes, list the hours (below) you will need to drive to attend

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

start

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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P

 

 

 

 

M

 

 

 

N

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Monday

 

 

Tuesday

 

 

Wednesday

 

 

Thursday

 

 

 

 

 

 

 

 

Friday

 

 

 

 

 

Saturday

 

 

 

Sunday

 

 

A/P

 

A/P

 

 

A/P

 

A/P

 

 

 

A/P

 

 

 

 

 

A/P

 

 

 

 

A/P

 

 

 

 

 

A/P

 

 

 

 

 

 

A/P

 

 

 

 

A/P

 

 

 

 

A/P

 

 

 

 

 

A/P

 

 

A/P

 

A/P

Start

or

Stop

or

Start

 

or

Stop

or

Start

or

 

 

Stop

 

 

or

Start

 

 

or

 

Stop

 

or

 

Start

 

or

Stop

 

or

 

Start

or

 

 

Stop

 

or

Start

 

or

Stop

or

M/N

M/N

 

M/N

M/N

M/N

 

 

 

M/N

 

M/N

 

 

M/N

 

M/N

M/N

 

M/N

 

 

M/N

 

M/N

M/N

9:15:

A

10:00

A

3:15:

 

A

3:45:

 

9:00:

 

 

 

 

5:00:

 

 

 

 

 

3:15:

 

 

 

 

 

3:45:

 

 

 

6:00:

 

 

 

 

12:00

 

 

N

6:00:

 

 

 

 

11:00

 

A

12:00

 

M

2:00:

A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3:00:

P

5:00:

P

11:30:

 

A

5:00:

 

:

 

 

 

 

:

 

 

 

 

 

11:30:

 

 

 

 

 

5:00:

 

 

 

6:00:

 

 

 

 

10:00

 

 

 

 

11:30

 

 

 

 

12:30

 

P

7:30:

 

A

10:30

A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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A

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P

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A

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:

 

 

 

 

 

 

:

 

 

 

 

 

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:

 

 

 

 

:

 

 

 

 

 

2:00:

 

 

 

 

6:00:

 

 

P

:

 

A

:

P

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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10:00

 

 

 

 

12:00

 

M

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A

:

P

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

:

A

:

P

:

 

A

:

 

:

 

 

 

 

:

 

 

 

 

 

 

:

 

 

 

 

 

:

 

 

 

 

:

 

 

 

 

:

 

 

 

 

 

:

 

 

 

 

:

 

 

P

:

 

A

:

P

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Monday

Hours 2:45

Tuesday

Hours 6:00

Wednesday

Hours 8:00

Thursday

Hours 6:00

Friday

Hours 10:00

Saturday

Hours 12:00

Sunday

Hours 5:00

Applicant Certification – Operating a motor vehicle, at the times and at the locations specified in this application, is necessary for fulfilling the duties of my occupation described above.

X JULIE M. CITIZEN

8/2/2014

TOTAL 49:45

HOURS

Examiner ID

(7)(Applicant Signature) Circuit Court

 

(Date – m/d/yyyy)

Court Signature

Court Signature Date (m/d/yyyy)

X

Distribution: 2 – WisDOT; 1 and 3 – Operator

APPLICATION FOR OCCUPATIONAL OPERATOR LICENSE

Wisconsin Department of Transportation

 

 

 

 

MV3027

11/2018

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(1) Applicant Name (First, Middle Initial, Last)

 

 

Birth Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Driver License Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Daytime Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

M

 

 

D

D

Y Y

Y Y

1 2

3

4

 

 

 

 

5

6

7 8

 

 

9 1 0 11 12

 

 

13 14

 

 

 

 

 

 

 

 

 

 

(2) OCCUPATION

 

 

EMPLOYER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(3) Occupational License Uses (Check ALL Necessary)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Church

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Emergency Service Provider

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Homemaker

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Student at:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have You Enrolled in a Driver Safety Plan

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(4) List ALL Counties or States in which you will be driving (Include your County of Residence)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If Yes, list the hours (below) you will need to drive to attend

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

start

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

stop

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A

 

 

 

P

 

 

M

 

 

 

 

 

 

 

N

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Monday

 

 

Tuesday

 

 

 

Wednesday

 

 

Thursday

 

 

 

 

 

 

 

Friday

 

 

 

 

 

Saturday

 

Sunday

 

 

 

 

 

 

 

A/P

 

A/P

 

 

A/P

 

A/P

 

 

A/P

 

 

 

 

 

A/P

 

 

 

A/P

 

 

 

 

A/P

 

 

 

 

 

 

A/P

 

 

 

 

A/P

 

 

 

 

A/P

 

 

 

 

 

 

A/P

 

 

A/P

 

A/P

 

 

 

Start

 

or

Stop

or

Start

 

or

Stop

or

Start

or

 

 

Stop

 

 

or

Start

 

or

 

Stop

or

Start

 

 

or

Stop

 

or

 

Start

or

 

 

 

Stop

 

or

Start

 

or

Stop

or

 

 

 

 

M/N

M/N

 

M/N

M/N

M/N

 

 

 

M/N

 

M/N

 

M/N

 

M/N

M/N

 

M/N

 

 

 

M/N

 

M/N

M/N

 

 

:

 

 

:

 

:

 

 

:

 

:

 

 

 

 

:

 

 

 

 

 

:

 

 

 

 

:

 

 

:

 

 

 

 

 

:

 

 

 

 

 

:

 

 

 

 

 

:

 

 

 

:

 

 

:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

:

 

 

:

 

:

 

 

:

 

:

 

 

 

 

:

 

 

 

 

 

:

 

 

 

 

:

 

 

:

 

 

 

 

 

:

 

 

 

 

 

:

 

 

 

 

 

:

 

 

 

:

 

 

:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

:

 

 

:

 

:

 

 

:

 

:

 

 

 

 

:

 

 

 

 

 

:

 

 

 

 

:

 

 

:

 

 

 

 

 

:

 

 

 

 

 

:

 

 

 

 

 

:

 

 

 

:

 

 

:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

:

 

 

:

 

:

 

 

:

 

:

 

 

 

 

:

 

 

 

 

 

:

 

 

 

 

:

 

 

:

 

 

 

 

 

:

 

 

 

 

 

:

 

 

 

 

 

:

 

 

 

:

 

 

:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

:

 

 

:

 

:

 

 

:

 

:

 

 

 

 

:

 

 

 

 

 

:

 

 

 

 

:

 

 

:

 

 

 

 

 

:

 

 

 

 

 

:

 

 

 

 

 

:

 

 

 

:

 

 

:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

:

 

 

:

 

:

 

 

:

 

:

 

 

 

 

:

 

 

 

 

 

:

 

 

 

 

:

 

 

:

 

 

 

 

 

:

 

 

 

 

 

:

 

 

 

 

 

:

 

 

 

:

 

 

:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

:

 

 

:

 

:

 

 

:

 

:

 

 

 

 

:

 

 

 

 

 

:

 

 

 

 

:

 

 

:

 

 

 

 

 

:

 

 

 

 

 

:

 

 

 

 

 

:

 

 

 

:

 

 

:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

:

 

 

:

 

:

 

 

:

 

:

 

 

 

 

:

 

 

 

 

 

:

 

 

 

 

:

 

 

:

 

 

 

 

 

:

 

 

 

 

 

:

 

 

 

 

 

:

 

 

 

:

 

 

:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Monday

 

 

 

 

Tuesday

 

Wednesday

 

 

 

 

 

 

 

 

Thursday

 

 

 

 

Friday

 

 

 

 

 

 

 

 

 

 

Saturday

 

 

 

 

 

 

 

Sunday

 

 

 

 

 

 

 

Hours

 

 

 

 

Hours

 

 

 

 

Hours

 

 

 

 

 

 

 

 

 

 

 

Hours

 

 

 

 

 

 

 

 

Hours

 

 

 

 

 

 

 

 

 

 

Hours

 

 

 

 

 

 

 

Hours

 

 

 

 

 

 

 

Applicant Certification – Operating a motor vehicle, at the times and at the locations specified in this application, is necessary for fulfilling the duties of my

 

TOTAL

 

 

 

 

 

 

 

 

occupation described above.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HOURS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Examiner ID

 

 

 

 

 

 

 

X

(7)(Applicant Signature) Circuit Court

 

(Date – m/d/yyyy)

Court Signature

Court Signature Date (m/d/yyyy)

X

Distribution: 2 – WisDOT; 1 and 3 – Operator