Traffic Division :: Pretrial Diversion Program Request Form

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Fields in Bold with an asterik must be completed in order to submit this Request form.

Ticket Number *		Ticket Number Required
Driver License No *		Driver License Number Required
Driver License State *	AL AK AZ AR CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NB NC NH NJ NM NV NY ND OH OK OR PA RI SC SD TN TX UT VT VA WA WI WV WY	Driver License State Required

First Name *		First Name Required
Last Name *		Last Name Required
Name Suffix	SR. JR. II III IV V
Middle Intial
Date Of Birth * (MM/DD/YYYY)		Date of Birth Required Invalid Birth Date
Street Address
City
State	AL AK AZ AR CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NB NC NH NJ NM NV NY ND OH OK OR PA RI SC SD TN TX UT VT VA WA WI WV WY
Zip Code
Phone Number
E-Mail Address *		EMail Address Required Invalid EMail Address
Verify E-Mail *		E-Mail does not match

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