Form PS31203 "Ignition Interlock Limited License" - Minnesota

What Is Form PS31203?

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

Form Details:

  • Released on October 1, 2014;
  • The latest edition provided by the Minnesota Department of Public Safety;
  • 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 fillable version of Form PS31203 by clicking the link below or browse more documents and templates provided by the Minnesota Department of Public Safety.

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Download Form PS31203 "Ignition Interlock Limited License" - Minnesota

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MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
I gn itio n In ter lo ck Limit ed Licen se
Driver Information
-
-
-
-
Driver's License Number
State of Issue
First Name
Middle Name
Last Name
Address
City/State/Zip
Phone Number
Date of Birth
Date of Application
Limited License Information
Indicate the days and times you are requesting to drive. Make sure to indicate A.M. or P.M. A limited license cannot be
issued for more than six (6) days and 60 hours per week for work, school, or child care needs with one specific day of
no driving. You must specify days and hours on any of the items listed below or it will not be written on the limited
license.
(enter day of week).
You must choose one day that you will NOT drive. I will NOT drive on
Place of Employment
Address
City/State/Zip
Occupation
Applicant's Postsecondary Education
Address
City/State/Zip
Child Care (custodial parents only)
Address
City/State/Zip
TO WORK/SCHOOL/CHILD CARE
TO HOME
JOB RELATED DRIVING TIME
DAY of WEEK
OTHER THAN TO AND FROM
Depart
Arrive
Depart
Arrive
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Tennessen Warning – Information collected on this form is used by the Department of Public Safety (DPS) to identify the person and as required by Minnesota
Statute. If you do not provide this information, DPS cannot enroll you in the Ignition Interlock Device Program. Personal information (name and address of
individuals) is classified as private data. DPS releases this information only as authorized or required by state and federal law.
PS31203-04
Rev. 10/14
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
I gn itio n In ter lo ck Limit ed Licen se
Driver Information
-
-
-
-
Driver's License Number
State of Issue
First Name
Middle Name
Last Name
Address
City/State/Zip
Phone Number
Date of Birth
Date of Application
Limited License Information
Indicate the days and times you are requesting to drive. Make sure to indicate A.M. or P.M. A limited license cannot be
issued for more than six (6) days and 60 hours per week for work, school, or child care needs with one specific day of
no driving. You must specify days and hours on any of the items listed below or it will not be written on the limited
license.
(enter day of week).
You must choose one day that you will NOT drive. I will NOT drive on
Place of Employment
Address
City/State/Zip
Occupation
Applicant's Postsecondary Education
Address
City/State/Zip
Child Care (custodial parents only)
Address
City/State/Zip
TO WORK/SCHOOL/CHILD CARE
TO HOME
JOB RELATED DRIVING TIME
DAY of WEEK
OTHER THAN TO AND FROM
Depart
Arrive
Depart
Arrive
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Tennessen Warning – Information collected on this form is used by the Department of Public Safety (DPS) to identify the person and as required by Minnesota
Statute. If you do not provide this information, DPS cannot enroll you in the Ignition Interlock Device Program. Personal information (name and address of
individuals) is classified as private data. DPS releases this information only as authorized or required by state and federal law.
PS31203-04
Rev. 10/14
Application for Ignition Interlock Limited License
Page 2
-
-
-
-
Driver's License Number
State of Issue
Other allowable driving (include travel time)
Court Appearances (must be related to the alcohol offense)
Address of Court House
City/State/Zip
A.M.
P.M.
Date of Appearance:
Leave Home
A.M.
P.M.
Return Home
Date of Appearance:
Leave Home
Return Home
A.M.
P.M.
A.M.
P.M.
Meeting with Probation Officer and/or DWI Court (MUST SPECIFY EXACT DATES AND TIMES)
Address
City/State/Zip
Date:
Leave Home
Return Home
A.M.
P.M.
A.M.
P.M.
Date:
Leave Home
Return Home
A.M.
P.M.
A.M.
P.M.
Chemical Dependency Treatment and/or Programs
Name of Treatment Facility
City/State/Zip
Address
Leave Home
Return Home
Check day(s):
A.M.
P.M.
A.M.
P.M.
Su
M
Tu
W
Th
F
Sa
Abstinence-based Support Group Meeting (up to a maximum of 3 support group meetings a week allowed)
Name of Support Group(s)
City/State/Zip
Address
Leave Home
Return Home
Check day(s):
A.M.
P.M.
A.M.
P.M.
Su
M
Tu
W
Th
F
Sa
Leave Home
Return Home
P.M.
Check day(s):
A.M.
Su
M
Tu
W
Th
F
Sa
A.M.
P.M.
Leave Home
Return Home
P.M.
Check day(s):
A.M.
P.M.
A.M.
Su
M
Tu
W
Th
F
Sa
FAX to: (651) 797-1299
EMAIL to: dvs.ii@state.mn.us
MAIL to: Driver and Vehicle Services, Ignition Interlock Unit, 445 Minnesota St., Suite 177, St. Paul, MN 55101
Tennessen Warning – Information collected on this form is used by the Department of Public Safety (DPS) to identify the person and as required by Minnesota
Statute. If you do not provide this information, DPS cannot enroll you in the Ignition Interlock Device Program. Personal information (name and address of
individuals) is classified as private data. DPS releases this information only as authorized or required by state and federal law.
PS31203-04
Rev. 10/14
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