Form DR-P073 "Employer's Sworn Statement in Support of Respondent's Application for Amended Employee Driver's Permit" - Hawaii

What Is Form DR-P073?

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

Form Details:

  • Released on July 1, 2018;
  • The latest edition provided by the Hawaii State Judiciary;
  • 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 DR-P073 by clicking the link below or browse more documents and templates provided by the Hawaii State Judiciary.

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Download Form DR-P073 "Employer's Sworn Statement in Support of Respondent's Application for Amended Employee Driver's Permit" - Hawaii

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Administrative Driver’s License Revocation Office (“ADLRO”)
American Savings Bank Tower, 1001 Bishop Street, Suite 500
Honolulu, Hawai‘i 96813
Telephone: (808) 534-6800 / Toll Free: 1-866-826-5656 / Fax: (808) 534-6888
Website:
www.courts.state.hi.us/courts/administrative/adlro
EMPLOYER’S SWORN STATEMENT IN SUPPORT OF
RESPONDENT’S APPLICATION FOR AMENDED EMPLOYEE DRIVER’S PERMIT
Employer Instructions: Submit this form together with employer’s business card and a copy of the
employer-owned motor vehicle registration(s) for the vehicle(s) that Respondent will be operating.
I, _______________________________________, swear or affirm that the following is true and correct:
Employer – Supervisor’s Name (First, M.I., Last)
1. Respondent is currently employed in a position that requires driving; and
2. Respondent will, in fact, be discharged from employment if Respondent is prohibited from driving
a vehicle not equipped with an ignition interlock device.
Respondent’s Name: _______________________________ Position/Job Title: ___________________
Employer – Company Name: _______________________________ Telephone No.:_______________
Employer Address: ___________________________________________________________________
City: ______________________________ State: __________________ Zip Code: _______________
I, the undersigned Employer – Supervisor, understand that any employee driver’s permit issued to
Respondent will include restrictions allowing Respondent to drive: 1) only during specified hours and only for
activities solely within the scope of Respondent’s employment; 2) only the vehicle(s) specified; and 3) only if
the permit is kept in Respondent’s possession while operating the employer’s vehicle. I also understand that
other appropriate restrictions may be imposed by ADLRO.
Employer Vehicle(s) - Color/Year/Make/Model & License Plate Number:
___________________________________________________________________________________
___________________________________________________________________________________
Days and Hours of Use:
______________________________________________________________________________
Restrictions on Vehicle Use (if any):
__________________________________________________________________
______________________________________________________________________________________________________
I further understand that an employee driver’s permit will not be issued to Respondent if: 1) Respondent’s
license is expired, suspended, or revoked as a result of action other than the instant revocation;
2)
Respondent did not hold a valid license at the time of Respondent’s arrest for the violation of §291E-61 of the
Hawai’i Revised Statutes (“HRS”); 3) Respondent holds either a category 4 license under HRS §286-102(b)
or a commercial driver’s license under HRS §286-239(b), unless the permit is restricted to a category 1, 2, or
3 license under HRS §286-102(b); or 4) Respondent is under the age of 18.
_________________________________________
________________________________
Employer – Supervisor’s Signature
Date
_________________________________________
Employer – Supervisor’s Position/Job Title
ADLRO EDP SS 07/18 Rev
RESET FORM
RG-AC-508 (11/18)
DR-P-073
Administrative Driver’s License Revocation Office (“ADLRO”)
American Savings Bank Tower, 1001 Bishop Street, Suite 500
Honolulu, Hawai‘i 96813
Telephone: (808) 534-6800 / Toll Free: 1-866-826-5656 / Fax: (808) 534-6888
Website:
www.courts.state.hi.us/courts/administrative/adlro
EMPLOYER’S SWORN STATEMENT IN SUPPORT OF
RESPONDENT’S APPLICATION FOR AMENDED EMPLOYEE DRIVER’S PERMIT
Employer Instructions: Submit this form together with employer’s business card and a copy of the
employer-owned motor vehicle registration(s) for the vehicle(s) that Respondent will be operating.
I, _______________________________________, swear or affirm that the following is true and correct:
Employer – Supervisor’s Name (First, M.I., Last)
1. Respondent is currently employed in a position that requires driving; and
2. Respondent will, in fact, be discharged from employment if Respondent is prohibited from driving
a vehicle not equipped with an ignition interlock device.
Respondent’s Name: _______________________________ Position/Job Title: ___________________
Employer – Company Name: _______________________________ Telephone No.:_______________
Employer Address: ___________________________________________________________________
City: ______________________________ State: __________________ Zip Code: _______________
I, the undersigned Employer – Supervisor, understand that any employee driver’s permit issued to
Respondent will include restrictions allowing Respondent to drive: 1) only during specified hours and only for
activities solely within the scope of Respondent’s employment; 2) only the vehicle(s) specified; and 3) only if
the permit is kept in Respondent’s possession while operating the employer’s vehicle. I also understand that
other appropriate restrictions may be imposed by ADLRO.
Employer Vehicle(s) - Color/Year/Make/Model & License Plate Number:
___________________________________________________________________________________
___________________________________________________________________________________
Days and Hours of Use:
______________________________________________________________________________
Restrictions on Vehicle Use (if any):
__________________________________________________________________
______________________________________________________________________________________________________
I further understand that an employee driver’s permit will not be issued to Respondent if: 1) Respondent’s
license is expired, suspended, or revoked as a result of action other than the instant revocation;
2)
Respondent did not hold a valid license at the time of Respondent’s arrest for the violation of §291E-61 of the
Hawai’i Revised Statutes (“HRS”); 3) Respondent holds either a category 4 license under HRS §286-102(b)
or a commercial driver’s license under HRS §286-239(b), unless the permit is restricted to a category 1, 2, or
3 license under HRS §286-102(b); or 4) Respondent is under the age of 18.
_________________________________________
________________________________
Employer – Supervisor’s Signature
Date
_________________________________________
Employer – Supervisor’s Position/Job Title
ADLRO EDP SS 07/18 Rev
RESET FORM
RG-AC-508 (11/18)
DR-P-073