Distracted Driving Education Program Form

Please fill out the form below if you wish to participate in the Distracted Driving Education Program.

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FIRST NAME *

LAST NAME *

DATE OF BIRTH

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MAILING ADDRESS *

CITY *

STATE *

ZIP CODE *

CITATION NUMBER *

EMAIL ADDRESS *

PHONE NUMBER *

I choose to enter a plea of NO CONTEST to the violation(s) on the citation listed above. *

Agree, I am entering a plea of No Contest.

I understand that if I complete an approved course and provide proof of completion of the course within 120 days, the fine amount will be suspended. *

Agree

I understand that my participation in this program will result in a conviction on my driving record. *

Agree

Additional Comments to Court Staff

Distracted Driving Education Program Form

Contact Information