Los Angeles Program Registration

FAX this form to: 
(909) 484-0154

                                                                             OR

 SEND this form to:
InterActive! Traffic School
Registration Department
 12223 Highland Blvd. Suite #241
Rancho Cucamonga, CA 91739
 

Please print out and fill out a copy of this form.
 Fax or mail this form filled out with your check information, check, money order or credit card number,
If you signed up for the Internet program, we will e-mail you (or call you if you don't have e-mail) 
when your payment has been processed so that you can begin your program.

 Fax orders will be processed within a few hours if received
during our regular business hours: Faxes sent at the end of the business day,
 will be processed by the following business day.
Monday-Friday 8:00 AM - 5:00 PM

If you are requesting the workbook program, you will need to login to the web site to view the PDF.

IMPORTANT: * Are REQUIRED Fields. Failure to fill in these fields
properly will result in a delay in the processing of your registration.

IMPORTANT! PLEASE PUT A CHECK MARK BY YOUR PROGRAM CHOICE:
INTERNET OR WORKBOOK

 ____Internet Program: $14.95

____PDF Workbook Program: $19.95

 

Case Number:

* Case, Citation or Docket  number: _________________
(Please omit all DASHES and SPACES.)
Password:
* Please write your desired password to enter the program here: ____________________

Personal Information:

* First and last name:
____________________________________________
* Street Address
____________________________________________
* City * State
_____________________________________ ______
* Zip:
____________________
* Driver's License Number
____________________________________________
* Phone
____________________________________
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 do not sell or market your information, this is our primary method of communication with you.)
____________________________________________
ISSUING COURT:
* Court Assigned Due Date:________________________________

Please write the FULL NAME (county & court name) of the court: 
(Ex: Los Angeles County-Malibu)
County: Los Angeles County

* Court Branch or City Name: _____________________________________________

Ex: Malibu (Failure to fill out the branch name correctly could result in a delay in the processing of your enrollment.)

SECURITY QUESTIONS

 Please fill out the following information. You will be asked these questions throughout your program. You must enter the answers exactly as you have done here, or you WILL NOT HAVE ACCESS TO YOUR PROGRAM!
The program IS case-sensitive.
* What is your mother's FIRST name? : 
NOT HER MAIDEN NAME- 
We recommend using all capital letters.		 ________________________
* How many pounds do you weigh ?: ________________________
* What COLOR was the car you were     
driving when you received your ticket?  
We recommend using all capital letters. : 		________________________
* Date of Birth :

_________________
Please follow this format :    mm  / dd    / yyyy
* What year does your driver's license expire? : _______
Please follow this format:      yyyy


PAYMENT INFORMATION


TOTAL TUITION:
Internet Program: $14.95
PDF Workbook Program:$19.95
 
CREDIT CARD  ____ Visa   ____  MasterCard   
____  American Express  ___ Discover
Credit Card Number:
__________________________________________________________
Expiration Date (MM/YY)
____________
Name (as it appears on the card):
__________________________________________________________
Signature of Cardholder:
__________________________________________________________


Program Registration by Check
(If you fill this out and FAX it in, 
you DO NOT need to SEND IN a paper check.)
This is just like writing us a check, 
where we can view all the same information on the paper draft.
Please Provide Name on this Checking Account  _______________________________
 Street Address on Check of Account Holder: _______________________________
City, State _______________________________
Zip Code _______________________________

Enter your Bank Name:

_______________________________

Bank City:

_______________________________

Bank State:

_______________________________

Bank Routing or "Transit" Number: This is the NINE digit number in the lower left corner of your check.
                                      
(This number MUST start with a 0,1,2 or 3.)

__ __ __ __ __ __ __ __ __ 

Your Account Number: Please DO NOT include your Routing or Check Number.
Please INCLUDE all leading zeros. Omit any spaces or characters.

_______________________________

Check Number: Please VOID the actual check with this number._____________________
Students that have drafts returned by the bank FOR ANY REASON, will have their Completion Certificate INVALIDATED with the court.

There WILL BE a $25.00 charge for any drafts returned 
by the bank for ANY REASON.

 By submitting this form to InterActive! Traffic School Online - With Internet Games and Cartoons, you authorize InterActive! Traffic School Online - With Internet Games and Cartoons to charge your credit card or draft your bank account  for the total program fee amount shown on this form. You acknowledge that you are the owner and authorized signer on the account information entered on this form.

 

Signature of Check holder:____________________________