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First Name: MI: Last Name:

Contact Information
Address As Written On The Ticket:*
City As Written On The Ticket:*
State As Written On The Ticket:*
Zip As Written On The Ticket:*
Is the address that is written on the ticket your correct MAILING address?*	Select One YES, Address on Ticket Correct NO, Address On Ticket Not Correct
Current Address:
Current City:
Current State:
Current Zip:

Phone and Email
Cell Phone:*
Home Phone:
Work Phone:
Email Address:*
Date Of Birth:*

Ticket Information
What Type of Ticket:	Speeding Ticket No Proof Of Insurance Stop Sign Electric Signal Violation Allowing Unlicensed Driver Assault Careless Driving Child Restraint Violation Closed Road Way Construction Zone Violation Defective Brake Lights Driving While Revoked Driving While Suspended Failure To Maintain Single Lane Fake License/Altered Plates Following To Close Illegal Turn Minor In Possession No Driver License No Headlights No Operators License No Plates Paraphernalia Possession Less Than 35 Grams Racing Speeding School Zone Speed To Fast For Conditions Theft Using Park Lot Avoid Intersection Wrong Way or Wrong Side of Street Window Tint Other
If Speeding How Fast? (E.G. 45 in a 20)
Ticket #: (top right-hand corner)
Other Description:
Second Ticket:	None Speeding Ticket No Proof Of Insurance Stop Sign Electric Signal Violation Allowing Unlicensed Driver Assault Careless Driving Child Restraint Violation Closed Road Way Construction Zone Violation Defective Brake Lights Driving While Revoked Driving While Suspended Failure To Maintain Single Lane Fake License/Altered Plates Following To Close Illegal Turn Minor In Possession No Driver License No Headlights No Operators License No Plates Paraphernalia Possession Less Than 35 Grams Racing Speeding School Zone Speed To Fast For Conditions Theft Using Park Lot Avoid Intersection Wrong Way or Wrong Side of Street Window Tint Other
If Speeding How Fast? (E.G. 45 in a 20)
Ticket #: (top right-hand corner)
Other Description:
Work Zone?*	Select One No Yes - no workers present Yes - workers present
School Zone?*	Select One No Yes - no children present Yes - children present
Did This Involve an Accident?*	Select One No Yes, but everyone is paid Yes, Matter still pending

Information About The Court or Police Department
Court or Police Department that gave you the ticket:* Look at the top left-hand corner of ticket to find court name
Court Address: This is usually found in the bottom right-hand portion of the ticket.
Court Number:
Court City:
Court State:
Court Zip:
Court Phone Number:
If there is a court date & time written on your ticket what are they?
IF no court date & time is listed, give us the date on which the ticket was "issued"

Information About Your Driving Record

Any tickets in the last 12 months?

Yes
No

Currently on Probation for other offenses?

Yes
No

License Currently Suspended or Revoked?

Yes
No

  Do you have any charges NOW PENDING in this or any other court?

Yes
No

If yes Fill in  

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After you send us your ticket information, our staff will contact you in short order about your case. You can decide if you wish to pay by credit card, check, or cash.