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IN THE WAYNE COUNTY MUNICIPAL COURT WOOSTER, OHIO STATE OF OHIO : Case No. ________________ Plaintiff : : MOTION FOR DRIVING PRIVILEGES vs. : : _______________________ : Defendant : This matter comes before the Court upon the motion of the Defendant for driving privileges. The driving privileges being requested are for the following purposes: Occupational purposes. 1. Place of Employment_______________________________________________ 2. Name of Direct Supervisor ___________________________________________ 3. Supervisor’s phone ________________________________________________ 4. Location(s)/ Address(s) of work_______________________________________ _________________________________________________________________ 5. Days and Hours of Work:____________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Educational purposes. 1. Name, location/address of School_____________________________________ _________________________________________________________________ 2. Days and Hours of School:___________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________

Medical purposes. Attach the confidential medical information sheet. Other requested purposes:_________________________________________ ________________________________________________________________ ________________________________________________________________ _______________________________ Defendant’s name _______________________________ Defendant’s Address _______________________________ ________________________________ ________________________________ ________________________________ Defendant’s Phone Number ________________________________ Defendant’s Social Security Number CERTIFICATE OF SERVICE I certify that a copy of this motion was mailed or hand delivered to the Prosecutor’s Office located at 215 N. Grant St., Wooster, Ohio 44691 on _______________, 20 ____. ________________________________ Defendant’s signature (Clerk of Courts will redact from public record.)