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2. REQUEST FOR DRIVING SAFETY COURSE
4. DATE:*
   DATE:

   DATE:
6. NAME:*
8. STREET ADDRESS:*
10. CITY, STATE AND ZIP:*
12. PHONE #:*
14. EMAIL:*
16. CITATION #:*
18. OFFENSE:*
20. I am entering a plea of:*

    1. GUILTY

    1. NO CONTEST
22. I am requesting to take a driving safety course and I meet ALL of the following requirements:*

    1. I am 17 years of age or older.
    2. I have a valid, non-commercial Texas driver’s license.
    3. I have at least minimum liability insurance coverage with my name listed as a driver.
    4. I have not taken a driving safety course for ticket dismissal within the last 12 months.
24. 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.
26. SUBMIT COPY OF DRIVER'S LICENSE*
28. SUBMIT COPY OF AUTO INSURANCE WITH YOUR NAME LISTED AS A DRIVER:*
30. I WISH TO RECEIVE MY PAPERWORK IN THE FOLLOWING MANNER:*

    1. By mail to the home address provided above

    1. By email to the email address provided above
32. ELECTRONIC SIGNATURE:*
    Please type full name and date in lieu of signature
34. Please contact the court office at 281-338-6702 if you have any questions.
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field