Driver Violation Certification Form
Document and certify details of a driver violation event. Please complete all relevant fields accurately.
Driver's Full Name
*
First Name
Last Name
Date and Time of Violation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Violation (Address or Intersection)
*
Vehicle Make and Model
*
Vehicle Plate Number
*
Type of Violation
*
Speeding
Running a Red Light
Reckless Driving
Failure to Yield
Distracted Driving
Other
Brief Description of Incident
*
Witness Name(s) (if any)
Reporting Officer or Supervisor Name
*
Actions Taken
*
Warning Issued
Citation Issued
Driver Suspended
Vehicle Impounded
Other
Certify Event
Should be Empty: