Los Angeles Program Registration

FAX this form to: 
(909) 484-0154

                                                                             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.

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

 ____Internet Program: $13.50

____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: $13.50
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:
__________________________________________________________

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.