2. Last Name*
3. First Name*
5. Date of Birth*
6. E-mail Address*
8. Mailing Address*
9. City and State*
10. Zip Code*
12. Citation Number*
13. Hearing Type

    1. Contested Hearing

    1. Mitigation Hearing
15. Electronic Signature Agreement*

    I declare under penalty and perjury of law that the information I have provided is true and correct to the best of my knowledge. I declare that I am the person issued the ticket.
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature.

    1. I agree.
17. Electronic Signature
Leave This Blank:


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

    This field is not part of the form submission.

21. Submit Submit and Print

* indicates a required field