Ticket Doctor - Ticket Submission Form

		Ticket Doctor
Ticket Submission Form

Submit Your Ticket

First Name:
Last Name:
Mailing Address:
City:
State:
Zip Code:
Date of Birth:
Phone Number:
Alternate Phone Number:
Email Address:
Do you have a Valid NY State License?
If No, please explain:

What is your license number? (located on top of your Drivers License).
Was there an accident involved?
Did you only receive this ONE ticket on THIS stop?
Do you have a criminal record?

What is your ticket number (upper left corner of ticket in bold)

What are your charges? (Speeding, Passed Stop Sign, etc):			What is the Section-Subsection code of your charge? (located above charge description, usually 4 digits and a letter)
Charge 1:			Charge 1 Code:
Charge 2:			Charge 2 Code:
Charge 3:			Charge 3 Code:
Charge 4:			Charge 4 Code:

What Court do you need to appear in?:
Appearance date?:			Appearance time?:

How did you hear about us?:

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