Form SF-1277 "Order for Restricted License (Class D, M)" - Tennessee

What Is Form SF-1277?

This is a legal form that was released by the Tennessee Department of Safety & Homeland Security - a government authority operating within Tennessee. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2016;
  • The latest edition provided by the Tennessee Department of Safety & Homeland Security;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form SF-1277 by clicking the link below or browse more documents and templates provided by the Tennessee Department of Safety & Homeland Security.

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Download Form SF-1277 "Order for Restricted License (Class D, M)" - Tennessee

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Order for Restricted License (Class D, M)
Tennessee Department of Safety
Driver Improvement Section
P.O. Box 25290, Nashville, TN 37202
RESTRICTED APPLICATION VALID FOR FREQUENT TRAFFIC (POINTS) SUSPENSION ONLY
Application must be filled out completely, signed and returned to the above address or returned to a Hearing Officer.
Approved applicants must file SR-22 insurance on personal vehicle and pay required fees. Faxed copies not accepted
NAME
DATE OF BIRTH
TN. DRIVER LICENSE #
ADDRESS
PHONE #
Authority: T.C.A. 55-50-331 & 55-50-505
I. Statement of person applying for restricted license or temporary driver license
I, ______________________________, have submitted the following personal information and statement
SIGNATURE
from my employer/school in presenting my request for a restricted driver license or temporary driver license, that I
need to drive to and from my place of employment and/or during the course of my employment or school. I understand
that if a restricted license or temporary driver license is issued to me, I will be able only to operate a motor vehicle as
stated on my application and that I MUST KEEP A COPY OF THIS APPLICATION WITH ME AT ALL TIMES.
Furthermore, upon violation of any restriction imposed by this order, I am subject to arrest and withdrawal of my
restricted driving privileges. I understand that any changes to my personal, employment or school information will
require a new application.
II, IMPORTANT! Application must be completely filled out with detailed address, days and times.
All information on application will be verified.
Employer
Address
Phone #
Days
Times
Secondary Employer
Address
Phone #
Days
Times
School
Address
Phone #
Days
Times
Daycare/School
Address
Phone #
Days
Times
Church
Address
Phone #
Days
Times
Doctor
Address
Phone #
Days
Times
Misc.
Address
Phone #
Days
Times
III. Supervisor’s Statement
Business Name
Address
Phone Number
Job Title
Overtime Required?
Times:
Yes_____
No______
Work
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Schedule
Days/Hours
Is employee required to drive for employment?
Does employee use personal vehicle?
Does employee use company vehicle?
If Yes Make
Model
Yes_____
No______
Yes_____
No______
Yes_____
No______
Describe the driving that is necessary
Supervisor signature
Phone Number
SF-1277 (Rev.07/16)
RDA 1415
Order for Restricted License (Class D, M)
Tennessee Department of Safety
Driver Improvement Section
P.O. Box 25290, Nashville, TN 37202
RESTRICTED APPLICATION VALID FOR FREQUENT TRAFFIC (POINTS) SUSPENSION ONLY
Application must be filled out completely, signed and returned to the above address or returned to a Hearing Officer.
Approved applicants must file SR-22 insurance on personal vehicle and pay required fees. Faxed copies not accepted
NAME
DATE OF BIRTH
TN. DRIVER LICENSE #
ADDRESS
PHONE #
Authority: T.C.A. 55-50-331 & 55-50-505
I. Statement of person applying for restricted license or temporary driver license
I, ______________________________, have submitted the following personal information and statement
SIGNATURE
from my employer/school in presenting my request for a restricted driver license or temporary driver license, that I
need to drive to and from my place of employment and/or during the course of my employment or school. I understand
that if a restricted license or temporary driver license is issued to me, I will be able only to operate a motor vehicle as
stated on my application and that I MUST KEEP A COPY OF THIS APPLICATION WITH ME AT ALL TIMES.
Furthermore, upon violation of any restriction imposed by this order, I am subject to arrest and withdrawal of my
restricted driving privileges. I understand that any changes to my personal, employment or school information will
require a new application.
II, IMPORTANT! Application must be completely filled out with detailed address, days and times.
All information on application will be verified.
Employer
Address
Phone #
Days
Times
Secondary Employer
Address
Phone #
Days
Times
School
Address
Phone #
Days
Times
Daycare/School
Address
Phone #
Days
Times
Church
Address
Phone #
Days
Times
Doctor
Address
Phone #
Days
Times
Misc.
Address
Phone #
Days
Times
III. Supervisor’s Statement
Business Name
Address
Phone Number
Job Title
Overtime Required?
Times:
Yes_____
No______
Work
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Schedule
Days/Hours
Is employee required to drive for employment?
Does employee use personal vehicle?
Does employee use company vehicle?
If Yes Make
Model
Yes_____
No______
Yes_____
No______
Yes_____
No______
Describe the driving that is necessary
Supervisor signature
Phone Number
SF-1277 (Rev.07/16)
RDA 1415
IV. Employer’s Insurance Information
(Complete only if driving employer’s vehicle)
Name and Address of Insurance company
Phone #
Policy Number
Policy Period:
From____________________ To___________________
Agents Signature
Date
Self-employed Applicant’s Statement
V.
You must submit with this order a written narrative explaining exactly why and when it will be necessary for you to
operate a motor Vehicle in the course of employment.
VI. Educational facility
If you are attending school, you must submit a copy of your class schedule, along with the record keepers name
and telephone number to verify the information.
_
__________________________________________________________________________________________
FOR DEPARTMENT USE ONLY
This Driver Improvement restricted application has been approved. The applicant must adhere to all restrictions
stated on this document. Restricted license valid in the State of Tennessee, travel outside of Tennessee would
require PRE APPROVAL from that State.
A
. Most direct route from residence to
:
PPROVED RESTRICTIONS
Employer
Days
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
From
To
Times
Secondary Employer
Days
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
From
To
Times
School
Days
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
From
To
Times
Daycare/School
Days
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
From
To
Times
Church
Days
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
From
To
Times
Doctor
Days
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
From
To
Times
Misc.
Days
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
From
To
Times
Hearing Officer Signature
Date
Approval Stamp
ATTENTION DRIVER EXAMINER: This individual has been authorized to obtain a restricted driver license or
temporary driver license with the restrictions listed above. This application must be signed, dated and
stamped by a hearing officer before issuing.
SF-1277 (Rev.07/16)
RDA 1415
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