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Fill out this form. Include your E-mail adress and or fax number for its return to you.You can also fax a copy of your ticket.
Before you fax the ticket, please go over the entries onthe ticket with a black pen.
Faxed copies will often be hard to read after a faxed transmission.
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Name
Phone
Fax
Email

1. Which DMV office notified you:
2. What DMV action is pending:
3. What is the effective date of the action:
4. Why is the DVM acting:



5. How many DMV points do you have:

a. In the last 12 months
b. In the last 24 months
c. In the last 36 months



6. Is your commercial license at stake:



7. Which court (s) convicted you or Forfeited your bail:

FIRST POINT IN TIME

a. First court location/name and court number
b. Vehicle code violation number
c. Date of conviction
d. Did you just pay the fine w/o an appearance before a judge?
e. Which state convicted you?
f. Was the point assigned b/c of an accident?

SECOND POINT IN TIME
a. Second court location/name/court number
b. Vehicle code violation number
c. Date of conviction
d. Did you just pay the fine w/o an appearance before a judge?
e. Which state convicted you?
f. Were you assigned a point b/c of an accident?

THIRD POINT IN TIME
a. Third court location/name/court number
b. Vehicle code violation number
c. Date of conviction
d. Did you just pay the fine w/o an appearance before a judge?
e. Which state convicted you?
f. Were you assigned a point b/c of an accident?

FOURTH POINT IN TIME

(unless you are a commercial driver earning 1.5 points per moving violation)

a. Fourth court location/name/court number
b. Vehicle code violation number
c. Date of conviction
d. Did you just pay the fine w/o an appearance before a judge?
e. Which state convicted you?
f. Were you assigned a point b/c of an accident?


8. Have you obtained a print out from your local DMV office


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