Form Center

2. First Name
3. Last Name
5. Date Of Birth
   Date Of Birth

6. I understand that I may be able to have this charge dismissed by successfully completing a Driving Safety Course or a Motorcycle Operating Training Course.

8. Plea

   By initialing each of the statements below, I swear that the following are true and correct to the best of my knowledge: 

   I waive my right to a jury trial or other hearing by the Court and enter a plea of (choose one):

   1. No Contest
   2. Guilty
10. Check those that apply

    1. I am not charged with speeding 25 mph or more over the speed limit.
    2. I am not charged with a moving violation that occurred in a construction zone with workers present.
    3. I am not charged with passing a school bus or leaving the scene of an accident.
    4. I do not possess a Commercial Driver’s License and did not possess one at the time of the offense.
    5. I understand that payment of $144 ($169 if in a school zone) in Court costs is required at the time of this request
    6. I am providing the Court with a copy of BOTH my valid Texas driver’s license and my proof of valid insurance which specifically names me as an insured driver
    7. I have not taken a Driving Safety Course in the 12 months preceding the date of my citation which is not reflected on my driving record and I am not in the process of completing one for another court.
    8. 90 days after receiving approval from the Judge, I will provide the Court with BOTH the Court Copy of my Driving Safety Course certificate and certified copy of my Driving Record as provided by DPS.
    9. I understand that this course must be a TDLR certified, 6 hour driving safety course. I also must provide a copy of the 3A version of my driving record.
    10. Lastly, I understand that failure to fully complete this form, provide a copy of my driver’s license, provide a copy of my insurance and/or failure to provide payment will result in denial of my request for Driving Safety Course.
12. Full Name
13. Today's Date
    Today's Date
15. Mailing Address
17. Phone Number
18. Email
Leave This Blank:


20. 1. Receive an email copy of this form.
21. Email address

    This field is not part of the form submission.

22. Submit

* indicates a required field