IN THE GENERAL SESSIONS CRIMINAL COURT
SHELBY COUNTY, TENNESSEE
STATE OF TENNESSEE ARREST DATE: ______________________________________________________
vs. DWI CONVICTION DATE: _____________________________________________
_______________________________________________________ DOCKET NO.: _______________________________________________________
(FULL NAME) (NOTICE TO COURT CLERK: PLEASE ATTACH
DATE OF BIRTH: ________________________________________
OTHER DISPOSITION & DATE: ________________________________________
DRIVER'S LICENSE NO.: __________________________________ (Implied consent cases)
Upon application of the defendant for a restricted driver's license, and it appearing to the court that the defendant has been
convicted in this Court of DWI (TCA 55-10-403), or suspended under the Implied Consent Law (TCA 55-10-406), and it further
appearing to the Court that the defendant needs a restricted driver's license for the purpose of driving to and from work and
while in the actual performance of the duties of said employment.
HOUSE ADDRESS: ____________________________________________________________________________________________________________________________
EMPLOYER (NAME & ADDRESS): ______________________________________________________________________________________________________________
WORK LOCATION (IF DIFFERENT FROM EMPLOYER'S ADDRESS): ________________________________________________________________________________
WORK HOURS: _______________________________________________________________________________________________________________________________
DRIVING PRIVILEGES AUTHORIZED BY COURT: _________________________________________________________________________________________________
It is, therefore, ORDERED that the defendant be issued a restricted driver's license for the purpose set forth above, subject to
the rules and regulations of the Department of Safety of the State of Tennessee.
This _________________________________ day of ________________________________ yr __________________
INSTRUCTIONS FOR ISSUANCE OF RESTRICTED DRIVER'S LICENSE
1. This form must be delivered to Driver's License Examining Station of your choice within thirty (30) days of this Court Order and present with (2) copies of the Order to the Driver's
License Examiner along with proof of liability insurance. Acceptable proof of insurance may be a liability insurance policy or written verification from an insurance company or
agency certifying that you are covered with insurance (applications for insurance cannot be accepted). After presenting the Court Order, an acceptable proof of insurance, and
upon passing the required driver's license examination, consisting of eye, written, and road test, a temporary driving permit will be issued. One (1) copy of the Court Order will be
returned to you to keep with your temporary driving permit until you receive your restricted driver's license.
2. An SR-22 form must be attached to this restricted driver's license from when it is delivered to Driver's License Examining Station if convicted of DWI. This form verifies your
insurance coverage to the Department of Safety. In order for your restricted driver's license to be mailed to you, the SR-22 form must be received in Nashville within 45 days from
the date of your driver's license test.
The SR-22 requirement applies to DWI's only, not to those suspended on Implied Consent.
3. Upon successfully passing the examination and paying the required fees to the Examiner (the fees of sixty-seven (67) dollars must be paid in cash only), the Examiner will issue a
temporary restricted license valid not to exceed sixty (60) days. As soon as the SR-22, if required, is received in Nashville, the Department of Safety will mail to you a restricted
license valid for the period of the suspension or revocation imposed by law.
4. You must be covered by liability insurance at all times to drive legally on a restricted license.
We are providing you with this information to expedite the issuance of your license.