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Please complete the following form. |
| When you are finished, click on the submit button. |
| NOTE: Please use capitalization AS YOU WOULD LIKE IT
TO APPEAR ON YOUR COMPLETION CERTIFICATE! |
| * Are Required Fields. |
| Use the TAB key to advance, Do NOT hit the Enter key. |
| * If you are doing the program for an Insurance Company Discount |
| Your DRIVERS LICENSE number will be your CASE NUMBER. |
| (citation or docket number) | |
| Retype Case Number : * | |
| (choose a password to enter the Activity area) | |
| Password : * | |
| Retype Password : * | |
| First Name : * | |
| Last Name : * | |
| Street Address:
This will be asked as a security question! * |
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| Address 2: | |
| City : * | |
| State : * | Zip * |
| Driver's License Number:
This will be asked as a security question! * |
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| Phone :
This will be asked as a security question!* |
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| E-mail Address : | (If you do not fill out a valid E-mail address, you will NOT receive a confirmation when we fax your certificate into the court!) We absolutely DO NOT sell or share e-mail addresses or student information with 3rd parties. This is our primary means of contacting you regarding your program or completion. |
| Court Assigned Due Date :
This will be asked as a security question!* |
/ / This WILL be printed on all paper completion certificates. |
| Please follow this format : | mm / dd / yyyy |
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* Please Choose the Approved Court Name Below!
This will be asked as a security question! $14.95 - Internet Program $19.95 - PDF Workbook Program Please DOUBLE CHECK after you choose to be sure the correct court name is displayed! | |
| FINAL 5 SECURITY QUESTIONS: | |
| IMPORTANT!! As an identity security measure, | |
| you will be asked the following questions AND the 5 security questions indicated above | |
| throughout your program. You will need to enter the information EXACTLY as you entered it below | |
| when the questions arise, or your program will become inaccessible. | |
| THESE ENTRIES ARE CASE-SENSITIVE! | |
|
What is your mother's FIRST name? (NOT
her Maiden name) :
* (We recommend using all capital letters.) |
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| How many pounds do you weigh?: * | |
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What COLOR was the car you
were driving when you received your ticket?:
* (We recommend using all capital letters. Please put in only ONE word.) |
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| Date of Birth : * | / / |
| Please follow this format : (Please put in a 0 if there is no number. EX: 09/02/1960 DO NOT PUT 2009 FOR THE YEAR!) |
mm/dd/yyyy |
| What year does your driver's license expire? : * | |
| Please follow this format : | yyyy |
![]() PLEASE CHECK YOUR ENTRIES TO YOUR SECURITY QUESTIONS BEFORE YOU CONTINUE! |
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| Access to your program will NOT BE POSSIBLE if the answers are not typed EXACTLY the same when the security questions appear! |
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©Copyright 1998-2010 InterActive Traffic School M. Pearl |
All Rights Reserved |