Form DAH H67 "Baiid Questionnaire" - Illinois

What Is Form DAH H67?

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

Form Details:

  • Released on February 1, 2020;
  • The latest edition provided by the Illinois Secretary of State;
  • 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 DAH H67 by clicking the link below or browse more documents and templates provided by the Illinois Secretary of State.

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Download Form DAH H67 "Baiid Questionnaire" - Illinois

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Office of the
Secretary of State
DEPARTMENT OF
ADMINISTRATIVE HEARINGS
B IID
Rm. 212 Howlett Bldg.
17 N. State, Ste. 1200
QUESTIONN IRE
501 S. 2nd St.
Chicago, IL 60602
Springfield, IL 62756
217-782-2192
www.cyberdriveillinois.com
YOU MUST ANSWER THESE QUESTIONS:
1.
What type of permit (s) are you requesting?
Employment
Medical
Support
Educational
Family Education
Day Care
BAIID Required RDP
2.
List the vehicle(s) (make, model, year) in which you will install the BAIID. Circle the vehicle(s) that you own.
3.
How many other drivers are in your household? Give names, ages and relationships.
4.
Do you take any prescription medications? If so, please list:
YOU MUST ANSWER THESE QUESTIONS IF YOU ARE REQUESTING A WORK PERMIT TO DRIVE A PERSONAL VEHICLE:
5.
What is your specific occupation?
6.
Are you requesting a permit to drive a personal vehicle:
to and from work?
Yes
No
on the job?
Yes
No
If yes, identify the vehicle by make, model, year.
YOU MUST ANSWER THESE QUESTIONS IF YOU ARE REQUESTING A WORK PERMIT TO DRIVE A WORK VEHICLE:
7.
Are you requesting a permit to drive a work vehicle:
to and from work?
Yes
No
on the job?
Yes
No
8.
Are you allowed to take one of these work vehicles home?
Yes
No
9.
Are you allowed to use the work vehicle for personal use?
Yes
No
10. Is there any other information about your employment situation that you believe is important in determining your specific
driving needs?
Under penalties of perjury as provided by law pursuant to Section 1-109 of the Code of Civil Procedure, the undersigned certi-
fies that the statements set forth in this Affidavit are true and correct.
Dated this___________________________ day of ______________________________________ 20 __________ .
___________________________________________ Driver’s License # _________________________________
Petitioner’s Name (print)
Petitioner’s Signature ___________________________________________________________________________
Telephone Number ( ___ ) _____________________________
( ___ ) _____________________________
Home
Work
Printed by authority of the State of Illinois. February 2020 — 2.5M — DAH H 67.5
Print
Reset
Office of the
Secretary of State
DEPARTMENT OF
ADMINISTRATIVE HEARINGS
B IID
Rm. 212 Howlett Bldg.
17 N. State, Ste. 1200
QUESTIONN IRE
501 S. 2nd St.
Chicago, IL 60602
Springfield, IL 62756
217-782-2192
www.cyberdriveillinois.com
YOU MUST ANSWER THESE QUESTIONS:
1.
What type of permit (s) are you requesting?
Employment
Medical
Support
Educational
Family Education
Day Care
BAIID Required RDP
2.
List the vehicle(s) (make, model, year) in which you will install the BAIID. Circle the vehicle(s) that you own.
3.
How many other drivers are in your household? Give names, ages and relationships.
4.
Do you take any prescription medications? If so, please list:
YOU MUST ANSWER THESE QUESTIONS IF YOU ARE REQUESTING A WORK PERMIT TO DRIVE A PERSONAL VEHICLE:
5.
What is your specific occupation?
6.
Are you requesting a permit to drive a personal vehicle:
to and from work?
Yes
No
on the job?
Yes
No
If yes, identify the vehicle by make, model, year.
YOU MUST ANSWER THESE QUESTIONS IF YOU ARE REQUESTING A WORK PERMIT TO DRIVE A WORK VEHICLE:
7.
Are you requesting a permit to drive a work vehicle:
to and from work?
Yes
No
on the job?
Yes
No
8.
Are you allowed to take one of these work vehicles home?
Yes
No
9.
Are you allowed to use the work vehicle for personal use?
Yes
No
10. Is there any other information about your employment situation that you believe is important in determining your specific
driving needs?
Under penalties of perjury as provided by law pursuant to Section 1-109 of the Code of Civil Procedure, the undersigned certi-
fies that the statements set forth in this Affidavit are true and correct.
Dated this___________________________ day of ______________________________________ 20 __________ .
___________________________________________ Driver’s License # _________________________________
Petitioner’s Name (print)
Petitioner’s Signature ___________________________________________________________________________
Telephone Number ( ___ ) _____________________________
( ___ ) _____________________________
Home
Work
Printed by authority of the State of Illinois. February 2020 — 2.5M — DAH H 67.5