Application for Driving Safety Course (Defensive Driving)

2. First Name*
3. Last Name*
5. Phone Number*
7. Address1*
9. Address2
11. City*
12. State*
13. Zip*
15. E-mail Address*
17. Ticket #*
19. Violation*
21. Do you have a valid Texas driver's license?*
    -- Select One --YesNo
22. Do you have current vehicle insurance in your name?*
    -- Select One --YesNo
24. Have you taken a Driving Safety Course within the past 12 months?*
    -- Select One --YesNo
25. Did you hold a commercial driver's license or did you hold a commercial driver's license on the date of the offense or offenses?*
    -- Select One --YesNo
27. How do you want to plea?*
    -- Select One --GuiltyNo Contest
29. Defendant Signature*
30. Date*
    Date
33. It is a state jail felony to make a false statement on this document.
Leave This Blank:


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

    This field is not part of the form submission.

37. Submit | Go Back