Defensive Driving Request

Last Name :*	First Name :*	Date of Birth:*
Mailing Address:*
City:*	State	Zip Code*
EMAIL Address :*	Contact Phone (xxx-xxx-xxxx):*

Citation # :	Citation Date :
Select an Offense :	If OTHER, please explain :

Did this offense occur within a school zone?	YES NO

I do solemnly swear or affirm that the following is true and correct: (If you are unable to initial each box, contact the court. You may not be eligible for Defensive Driving.)		Your Initials
I am the person named in the above-referenced citation.

I possess a valid Texas driver's license.

I do not possess a Commercial Driver's License (CDL).

I have not taken Defensive Driving to have a ticket dismissed in the last 12 months.

I possess a valid automobile insurance policy with my name on the policy as a covered driver.

I understand that if I fail to complete Defensive Driving in a timely manner, the maximum fine plus court costs will be assessed and the citation will appear on my record.

By completing this form and pressing the "Select" button, I am hereby entering a plea of "no contest;" I waive my right to a jury trial; and I request Defensive Driving.
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