2. Traffic Enforcement Request
4. First Name*
5. Last Name*
7. Address*
9. City*
10. State*
11. Zip Code*
13. Phone Number*
14. Cell Number
16. Email Address*
18. Type of Offense:*
    -- Select One --Please SelectSpeedingSchool Zone ViolationStop Sign ViolationStop Light ViolationOther Sign ViolationRight of Way ViolationTurning ViolationCrosswalk/ Pedestrian ViolationParking ProblemOther
20. Violations Occur on the Following Day(s):*
    -- Select One --Day(s) of the WeekMondayTuesdayWednesdayThursdayFridaySaturdaySunday
21. Violations Occur at the Following Time(s)*
    -- Select One --Time(s) of Day6:00am7:00am8:00am9:00am10:00am11:00am12:00 Noon1:00pm2:00pm3:00pm4:00pm5:00pm6:00pm7:00pm8:00pm9:00pm10:00pm11:00pm12:00 Midnight1:00am2:00am3:00am4:00am5:00am
23. Enforcement Location*
    Examples: 123 Main Street or 1St Street and Main Street.
25. Additional Details*
    Use this space to add additional information about the location, vehicle, or description of the violation.
27. Electronic Signature Agreement

    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, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
29. Electronic Signature*
30. Date*
    Date
Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field