Traffic Violation Contact Form

First Name

Last Name

Middle Name

Date of Birth

Street Address

Apartment Number



Zip Code

Cell Phone Number

Home Phone

Emergency Contact Phone Number

Emergency Contact

Your Email

Do you have a valid driver's license?
 Yes No
What is your driver's license number?

Do you have a commercial driver's license?
 Yes No

What is the ticket or citation number?

What court is your ticket in?

What were you given the ticket for?

Is your ticket in past due or warrant status?
 Yes No
Have you taken Defensive Driving in the past twelve (12) months?
 Yes No
Do you have a court date scheduled?
 Yes No
If you do have a court date, what is the date?

If you do have a court date, what is the time?

Do you have insurance coverage?
 Yes No
Do you have any additional comments or questions?
You may upload a picture of your ticket/citation