Fillable Driver Improvement Registration Form printable pdf download

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REGISTRATION FORM FOR DRIVER IMPROVEMENT PROGRAM

Name:________________________________________________________________________________

Sex:________

Last

First

M.I.

Address: ______________________________________________________________________________________________

Street

Apt#

Address: ______________________________________________________________________________________________

CITY

STATE

ZIP

Date of Birth: _______/_______/_______

Daytime Phone: (______) _____________________

Evening Phone: (______)______________________

Driver’s License # ____________________________

Licensing State __________________________________

Date of Violation _______/_______/_______

Ticket # ________________________________

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Have you had any other traffic tickets within the last 12 months? _____ Yes

_____ No

Have you been placed on supervision or attended a

Driver’s Safety Class within the last 12 months in any jurisdiction? _____ Yes

_____ No

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

*VIOLATOR MUST ATTEND THE CLASS WITHIN 90 DAYS OF THE FIRST APPEARANCE DATE.

REGISTRATION FORM FOR THE DRIVER IMPROVEMENT PROGRAM.

What day do you want to attend class?

Wednesday at 6:00 p.m. - 10:00 p.m.

Saturday at 8:30 a.m. - 12:30 p.m.

____

LaSalle County Driver Improvement Program at IVCC, Oglesby, IL 61348 ( pay ticket plus $35.00 for class).

Confirmation of class date will be sent to you by mail or given to you if you appear in person.

Classes are offered Saturday morning from 8:30 a.m. to 12:30 p.m or Wednesday Evening from 6:00 p.m. to

10:00 p.m. The Driver Improvement Program reserves the right to change time, day and location of class on an as

needed basis.

If you miss or are late for class YOU MUST reschedule and pay a $10.00 fee.

_____ CLASS LOCATION:

Illinois Valley Community College

The 4 hour class is completed in one

815 N. Orlando Smith Ave.

appointment. (Sign Language is

Oglesby, IL 61348

available upon request)

ANOTHER STATE or in ANY OTHER ILLINOIS COUNTY besides LaSalle you may attend

_____ LaSalle County Driver Improvement Program. (pay ticket plus $35.00 for class) or

_____ Take an approved 4 hour class in another jurisdiction (pay ticket plus fill out DRIVER IMPROVEMENT APPLICATION

completely. (You are responsible to locate a class and pay their registration fee)

When taking the Class in another Jurisdiction (ON LINE COURSES NOT ACCEPTED) you must send the original

certificate to us within 90 days of your first appearance date or you will be revoked and your guilty plea used to

enter a conviction and reported to the Secretary of State.

This form with payment needs to be in our office at least 3 WORKING DAYS before the first appearance date (noted on the

bottom half of the front side of the ticket). Make sure you have included the correct payment amount and type of

payment with your application or it will be returned to you. You will not receive Court Supervision unless the

completed form is received back with the additional amount due at least 3 working days before your court date.

If you have any questions contact the Driver Improvement Program at LaSalle County Circuit Clerk’s Office at (815) 434-8271.

Mail form and payment to:

PAYMENT OPTIONS (DO NOT SEND CASH) IF YOU ARE PAYING BY VISA/MASTERCARD/

ANDREW F. SKOOG

DISCOVER, FILL OUT THE FORM BELOW AND SIGN YOUR NAME.

A. PERSONAL CHECK, MONEY ORDER, OR VISA/MASTERCARD//DISCOVER ARE ACCEPTED.

LASALLE COUNTY CIRCUIT CLERK

* All checks and money orders are made payable to:”CLERK OF THE CIRCUIT COURT.”

707 EAST ETNA ROAD, ROOM 141

DO NOT SEND CASH

OTTAWA, ILLINOIS 61350

Print My Name as it appears on the card ___________________________ Signature x_______________________________

Address: ________________________________________

City ____________________ State: _____ Zip__________

MasterCard

Visa

Number: ___-___-___-___

___-___-___-___

Discover

Expiration Date:

(Note: A service charge of $4.00 or the applicable bank processing fee, whichever

_____/_____/_____

is greater, will be added to this transaction if credit card is used for payment.)

Driver Improvement Registration Form

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