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

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26. Submit Submit and Print

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