Pre-filled Paperwork Hardship Waiver Application Student Information Student Name (Last, First, Middle) * Student Age Date of Birth * Street Address (Number and Street) * City * State * Zip Code * DLN * Student Phone * Reason for Waiver Request (Select One) The applicant is the only licensed driver in the applicant’s household, a household member who owns or leases a properly registered motor vehicle, and a household member needs the applicant to operate the motor vehicle to enable the household member to receive regularly required medical care. Application must include a letter from the household member’s physician indicating frequency and duration of medical care. The applicant must be the primary means of financial support for the family and no alternative means of transportation exists from another family member or from public transportation to travel to and from the applicant’s place of employment. Application must include verification of employment with working hours on letterhead from applicant’s employer. The applicant has no licensed driver in the state of Indiana who can supervise practice driving. Additional Information * How many individuals in your household presently hold a valid license? * Place and Location of Employment (city) * Working Hours Is public transportation available in your area? Yes Leave Blank for No Reason for Waiver * I am requesting a waiver because I have only recently come to this country as a refugee. It is vital that I earn my license as quickly as possible to allow me to get to appointments and shop for groceries. I have no family or acquaintences in Indiana to help me practice, but I am currently taking lessons through a driving school. State your reason(s) for requesting a waiver. I swear or affirm under the penalties of perjury that the information I have entered on this form and any attached documents is correct. I understand that making a false statement may constitute the crime of perjury. Signature of Applicant * signature keyboard Clear Type the name of the applicant here to sign waiver request Printed Name * Type name of applicant Please upload any supporting documentation Choose File Maximum file size: 52.43MB Submit If you are human, leave this field blank. 50 Hour Log Sheet Student Contact (optional) Completed 50 hour log sheet will be sent to Drive Zone whether this is completed or not. Email * Email Email Student Information Student Name * Last, First, Middle Initial Driver's License/Permit Number * On Permit listed as DLN Permit Issue Date * Student Signature (Optional) signature keyboard Clear Student can sign hard copy if left blank Date 2 Date3 Date4 Date5 Date6 Date7 Date8 Date9 Date10 Date11 Date12 Date13 Date14 Date15 Date16 Date17 Date18 Date19 Date20 Date21 Date22 Date23 Date24 Date25 Date26 Date27 Date28 Date29 Date30 Date31 Date32 Date33 Date34 Date35 Date36 Submit If you are human, leave this field blank.
