
APPLICATION FOR SPECIAL PERMIT TO
OPERATE A MOTOR VEHICLE TO AND FROM WORK
A-62 REV. 4-2010
STATE OF CONNECTICUT
DEPARTMENT OF MOTOR VEHICLES
DRIVER SERVICES DIVISION
60 STATE STREET, WETHERSFIELD, CT 06161-2530
TELEPHONE: (860) 263-5720
On The Web At ct.gov/dmv
INSTRUCTIONS:
1. Please print or type.
2. Multiple employment requires separate applications.
3. A $100.00 non-refundable application fee in the form of a check or money order payable to DMV must accompany each request for a permit.
Operation of motor vehicles requiring a CDL or used for Public Passenger Transportation is PROHIBITED under the Special Permit Program
NAME OF APPLICANT (Last, First, Middle) DATE OF BIRTH OPERATOR LICENSE NUMBER/STATE
SEX
M F
MAILING ADDRESS (Number and Street) (City or Town) (State) (Zip Code)
RESIDENCE ADDRESS (If different) (City or Town)
(State) (Zip Code)
NAME OF EMPLOYER (If self-employed, include business name and legal proof of self-employment)
ADDRESS OF EMPLOYER
OCCUPATION
HOME TELEPHONE NUMBER
DAYS AND HOURS OF EMPLOYMENT (Specify A.M. or P.M.)
(City or Town) (State) (Zip Code)
MON.
TUE.
WED.
THU.
FRI.
SAT.
SUN.
TO BE ISSUED A WORK PERMIT, YOUR
SCHEDULE MUST BE CLEARLY IDENTIFIED, AND
MAY NOT EXCEED A CONTINUOUS 12-HOUR
PERIOD PER DAY.
IF YOU HAVE MORE THAN ONE PLACE OF
EMPLOYMENT, EACH EMPLOYER MUST
COMPLETE A SEPARATE APPLICATION.
What is the distance and the commuting time from your residence to your place of employment?
Is public transportation available
from your residence to your
place of employment?
YES NO
What significant hardship(s) will you suffer without a Special Operator's Permit?
What efforts have you made to obtain other transportation?
Your operator's license is under suspension. If you operate any vehicle outside of the authorized hours, you may be subject to arrest. If you operate a
motor vehicle for a purpose not authorized by law, a police officer may make a report to the Commissioner of Motor Vehicles and you will be subject to a
civil penalty of up to $500. If your operator's license is suspended for another reason while you are in possession of this permit, the permit is revoked,
and if you thereafter operate a motor vehicle you will be subject to double the penalties imposed by law. If you alter or make improper use of the permit,
you will be subject to criminal penalties.
I swear or affirm under penalty of false statement in accordance with Connecticut General Statute 53a-157, and subject to penalties for perjury for a
deliberate false statement, that the above information and any attachment hereto is true and correct.
NOTICE:
OATH:
PRINTED NAME OF SUPERVISOR SIGNATURE OF SUPERVISOR
X
PRINTED JOB TITLE OF SUPERVISOR WORK TELEPHONE
PRINTED NAME OF APPLICANT SIGNATURE OF APPLICANT
X
DATE SIGNED
DMV USE ONLY
PERMIT:
APPROVED DENIED
DATE PERMIT ISSUED PERMIT VALID UNTIL
(If Approved)
(If Approved)
REASON FOR DENIAL
DRIVING HISTORY NO SIGNIFICANT HARDSHIP INELIGIBLE OTHER (Provide Details)
DATE SIGNEDAUTHORIZED SIGNATURE (DMV)
X
(Number and Street)
(Number and Street)
PRINTED NAME
( )
( )
YOUR OFFICIAL DRIVING RECORD WILL BE REVIEWED AS PART OF THIS APPLICATION.
INABILITY TO CONFIRM YOUR EMPLOYMENT MAY RESULT IN DENIAL OF YOUR SPECIAL OPERATOR'S PERMIT.