(1) Application for a medical hardship driving permit shall be made to the Department of Motor Vehicles on forms furnished for that purpose by the department. The application form shall contain such information as deemed necessary by the director to carry out this section and section 60-4,130.01. If the department has a digital image and digital signature of the applicant preserved in the digital system implemented under section 60-484.01, the medical hardship driving permit, if issued, may contain such image and signature. The application form shall also include a voter registration portion pursuant to section 32-308 and the following specific question: Do you wish to register to vote as part of this application process? To be eligible for a medical hardship driving permit, the applicant shall furnish, along with the application to the director, the following:

(a) An affidavit from the applicant's physician stating that it is necessary for such applicant to receive medical treatment at a location other than the applicant's residence and that the treatment will not impair the applicant's ability to operate a motor vehicle; and

(b) An affidavit stating that there exists no other reasonable alternative means of transportation to and from the site of medical treatment available to the applicant.

(2) The applicant shall also be required to file and maintain proof of financial responsibility as required by the Motor Vehicle Safety Responsibility Act.

(3) The fee prescribed in section 60-4,115 shall be submitted to the department along with the application for a medical hardship driving permit.

(4) When the holder of a medical hardship driving permit is convicted, on or after the date of issuance of the permit, of any traffic violation or of operating a motor vehicle for a purpose other than specified by such permit, the person shall not be eligible to receive another medical hardship driving permit during that particular period of revocation.

(5) Any person who feels himself or herself aggrieved because of the refusal of the director to issue the medical hardship driving permit may appeal in the manner set forth in section 60-4,105.