Driver's Safety Course Request

2. FIRST NAME*
3. LAST NAME*
5. ADDRESS*
7. CITY*
8. STATE*
9. ZIP*
11. DATE OF BIRTH*
    DATE OF BIRTH
12. PHONE NUMBER*
13. EMAIL ADDRESS*
15. CITATION NUMBER*
16. ISSUE DATE
    ISSUE DATE
17. VIOLATION*
    Please enter the reason for your citation.
19. DRIVER'S LICENSE UPLOAD*
    You must attach a scanned copy of your Driver's License and Current Proof of Insurance for you to be granted the option of Driver's Safety Course.
20. INSURANCE CARD UPLOAD
    You must attach a scanned copy of your Driver's License and Current Proof of Insurance for you to be granted the option of Driver's Safety Course.
22. * indicates a required field
Leave This Blank:


24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit Submit and Print

* indicates a required field