Driving Safety Request Form

DRIVING SAFETY COURSE REQUEST FORM

You may be able to request that one charge (moving violation only) be dismissed by successfully completing a driving safety course (or a motorcycle operator training course You may lose that right if you do not provide the Court with the completed application of your request to take the course on or before your appearance date.
Name Print or type as it appears on your drivers license
Drivers License Number
Citation No
Violation
Appearance Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Daytime Telephone Number
Format: (000) 000-0000.
Email
example@example.com
I hereby enter my plea of
I am providing a copy of my valid Texas driver's license or permit. I do not hold a CDL license.

Cancelof
I am providing a copy my vehicle liability insurance certificate with this application.

Cancelof
ALL LINE ITEMS BELOW MUST BE CHECKED THAT YOU UNDERSTAND
I, Your name* confirm that on the date of my request for a driving safety course (motorcycle operator training course) in the above number cause that I was not taking such a course nor had I completed one within the 12 months preceding the date of my current offense that is not shown on my driving record as maintained by the Texas Department of Public Safety (or as maintained by the state that issued my driver's license - active military personnel only).
Defendant's Signature
Date

MonthDayYear
Date
Should be Empty: