Please fill out the registration form completely. Asterisks (*) indicate required fields.

FIRST NAME	MI	LAST NAME	III, Jr., Sr., etc.
Enter your name as it appears on your current valid driver's license.  Do not enter any blank spaces before or after your name.
PROMOTIONAL CODE (if applicable)
DRIVER'S LICENSE NUMBER
DL STATE	Texas Other Texas driver's License should contain numbers only (do not enter letters).
MAILING ADDRESS
CITY
STATE	AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY
ZIP CODE
PHONE NUMBER     (Home or Office)	- -
E-MAIL
	(Click here if you don't have an e-mail address)
COURT AS IT APPEARS ON CITATION
	(If you are not sure of the court name, you may continue with registration and enter this information at the end of the course)
	(Click here if you wish to enter the court name at the end of the course.)
	(Click here if taking course for insurance reduction.)
CHOOSE PASSWORD
CONFIRM PASSWORD
HOW DID YOU HEAR ABOUT US? Select One	Newspaper Internet Radio TV Billboard TXDriving.com Direct Mail E-Mail Yellow Pages Other
Please enter the information below regarding a vehicle registered in your last name. This may be different than the vehicle in which you received a ticket. Please do not enter dashes or spaces.
MOTOR VEHICLE INFORMATION Select One	License Plate Number (May be different than the vehicle in which you received a ticket)  (Do not enter spaces)
	No Car / Non-Texas Vehicle Registration 1
	Fill in Later    (You will be prompted to enter your license plate number before beginning Lesson 3. If you do not enter your license plate number at the prompt, you will be required to submit a notarized Statement of Assurance before a Certificate of Completion can be issued.)
	1 If you choose this option DefensiveDriving.com will be unable to verify your information using a 3rd party database. The state requires that you must submit a signed and notarized Statement of Assurance along with a copy of your driver's license to DefensiveDriving.com before we can issue you a Certificate of Completion. You will be able to print the form later in the course.