DRIVING SAFETY COURSE FORM

PLEASE ENCLOSE YOUR TICKET

PERSONAL CHECKS WILL NOT BE ACCEPTED

AFFIDAVIT AND REQUEST TO TAKE A DRIVING SAFETY COURSE

THE STATE OF TEXAS	IN THE JUSTICE COURT
VS.	PRECINCT __________
______________________________________	GREGG COUNTY, TEXAS

I HEREBY ENTER A PLEA OF NO CONTEST AND REQUEST THE DRIVING SAFETY COURSE (DSC). I HAVE ENCLOSED A MONEY ORDER FOR $105.00, A COPY OF MY LIABILITY INSURANCE COVERAGE AND I HAVE SIGNED AND DATED THE SPACE BELOW. I AM NOT CURRENTLY TAKING DSC NOR HAVE I COMPLETED DSC WITHIN THE LAST 12 MONTHS. I UNDERSTAND IT IS MY RESPONSIBILITY TO TAKE DSC AND I WILL NOT RECEIVE ANYTHING FROM THE COURT. FURTHER, I UNDERSTAND IF I FAIL TO FURNISH THE COURT WITH MY CERTIFICATE OF COMPLETION AND MY DRIVING RECORD WITHIN 90 DAYS FROM THE DUE DATE ON MY CITATION- A WARRANT WILL BE ISSUED FOR MY ARREST

SIGNATURE _____________________________________

ADDRESS _______________________________________

CITY, STATE, ZIP _________________________________

DAYTIME PHONE NUMBER _______________________

SWORN AND SUBSCRIBED BEFORE ME BY AFFIANT ON THIS THE ____ DAY OF ____________, 2____.

________________________________________________ NOTARY OF PUBLIC