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Los Angeles Program Registration |
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FAX this form to: OR |
SEND this form to:
InterActive! Traffic School Registration Department 324 East 11th Street Suite F-4 Tracy, CA 95376 |
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 - 4:30 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.
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IMPORTANT! PLEASE PUT A CHECK MARK BY YOUR PROGRAM
CHOICE: INTERNET OR WORKBOOK ____Internet Program: $13.50 ____PDF Workbook Program: $19.95 |
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Case Number: |
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*
Case, Citation or
Docket number: _________________
(Please omit all DASHES and SPACES.) |
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| Password: | ||||||||||||||||||||||||
| * Please write your desired password to enter the program here: ____________________ | ||||||||||||||||||||||||
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Personal Information: |
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| * 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.) |
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| ____________________________________________ | ||||||||||||||||||||||||
| ISSUING COURT: | ||||||||||||||||||||||||
| * Court Assigned Due Date:________________________________ | ||||||||||||||||||||||||
Please write the FULL NAME (county & court name) of the court: (Ex: Los Angeles County-Malibu) |
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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.) |
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SECURITY QUESTIONS |
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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! |
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| CREDIT CARD | ____
Visa ____ MasterCard ____ American Express ___ Discover |
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| Credit Card Number: | ||||||||||||||||||||||||
| __________________________________________________________ | ||||||||||||||||||||||||
| Expiration Date (MM/YY) | ||||||||||||||||||||||||
| ____________ | ||||||||||||||||||||||||
| Name (as it appears on the card): | ||||||||||||||||||||||||
| __________________________________________________________ | ||||||||||||||||||||||||
| Signature of Cardholder: | ||||||||||||||||||||||||
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__________________________________________________________ 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 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. |
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