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Request for Driving Safety Course
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REQUEST FOR DRIVING SAFETY COURSE
DATE:
*
DATE:
DATE:
NAME:
*
STREET ADDRESS:
*
CITY, STATE AND ZIP:
*
PHONE #:
*
EMAIL:
*
CITATION #:
*
OFFENSE:
*
I am entering a plea of:
*
GUILTY
NO CONTEST
I am requesting to take a driving safety course and I meet ALL of the following requirements:
*
I am 17 years of age or older.
I have a valid, non-commercial Texas driver’s license.
I have at least minimum liability insurance coverage with my name listed as a driver.
I have not taken a driving safety course for ticket dismissal within the last 12 months.
I understand that this form is just a request to take a driving safety course and that nothing has been granted by the judge at this time. I understand I must submit this request with a copy of my Texas driver’s license and current liability auto insurance before my court date.
SUBMIT COPY OF DRIVER'S LICENSE
*
SUBMIT COPY OF AUTO INSURANCE WITH YOUR NAME LISTED AS A DRIVER:
*
I WISH TO RECEIVE MY PAPERWORK IN THE FOLLOWING MANNER:
*
By mail to the home address provided above
By email to the email address provided above
ELECTRONIC SIGNATURE:
*
Please type full name and date in lieu of signature
Please contact the court office at 281-338-6702 if you have any questions.
Leave This Blank:
Receive an email copy of this form.
Email address
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