Client Driving Privledge Form For The Huey Defense Firm

Step 1 of 4

Full name*
Address
Street Address Address Line 2 City Ohio ZIP Code
Phone number

Last 4 digits of your Social Security number
Date of birth
Date Format: MM slash DD slash YYYY
Driver's license number (on ticket) and state
Insurance Company, Policy Number, and Agent name

Work and School
Enter your employer's information below
If you have more than one job, click the (+) to add another.
Name City State Zip code
Enter your school's information below:
If you have attend more than one school, click the (+) to add another.
Name City State Zip code
Work and School Schedule
In completing the below, please use EARLIEST time you NORMALLY leave for work and the LATEST time you NORMALLY can expect to be home.

If periodically you leave earlier or later or work outside these NORMAL hours, don’t use that time but explain that after completing this table.
Employer
What are your arrival and departure times throughout the week? Enter the times in the designated fields. There should be seven rows, one for each day of the week. To add another day/row, click the (+) plus icon.
Day Leave Home Arrive Work Leave Work Arrive Home
Explanation for employer 1
Do you need to add more employers?
- Yes
- No
Employer 2
What are your arrival and departure times throughout the week? Enter the times in the designated fields. There should be seven rows, one for each day of the week. To add another day/row, click the (+) plus icon.
Day Leave Home Arrive Work Leave Work Arrive Home
Explanation for employer 2
Employer 3
What are your arrival and departure times throughout the week? Enter the times in the designated fields. There should be seven rows, one for each day of the week. To add another day/row, click the (+) plus icon.
Day Leave Home Arrive Work Leave Work Arrive Home
Explanation for employer 3
School
What are your arrival and departure times throughout the week? Enter the times in the designated fields. There should be seven rows, one for each day of the week. To add another day/row, click the (+) plus icon.
Day Leave Home Arrive Work Leave Work Arrive Home
Explanation for school (if applicable)
Do you need to add more schools?
- Yes
- No
School 2
What are your arrival and departure times throughout the week? Enter the times in the designated fields. There should be seven rows, one for each day of the week. To add another day/row, click the (+) plus icon.
Day Leave Home Arrive Work Leave Work Arrive Home
Explanation for school 2 (if applicable)
School 3
What are your arrival and departure times throughout the week? Enter the times in the designated fields. There should be seven rows, one for each day of the week. To add another day/row, click the (+) plus icon.
Day Leave Home Arrive Work Leave Work Arrive Home
Explanation for school 3 (if applicable)

Driving during work...
Do you drive during your work? Is it done during the above hours or outside the above hours? Explain below:
If your schedule varies, please attach a copy of your work schedule below:
Take a picture of it or scan it and upload the document here (if you can).
Accepted file types: jpeg, jpeg, png, pdf.
More information
Please note any other reasonable/necessary requests for driving below, please describe when that driving would be (is it regularly the same time and day) and if you would have documentation supporting it (such as AA attendance sheet, appointment letter from doctor):
Please explain any of the above including times of driving requested (if knowable):

Name	City	State	Zip code

Name	City	State	Zip code

Day	Leave Home	Arrive Work	Leave Work	Arrive Home

Day	Leave Home	Arrive Work	Leave Work	Arrive Home

Step 1 of 4

Work and School

Work and School Schedule