EC DUI School Service Request Registration Form

A member of our team will contact you within 24-hours.

Full Name

Date of Birth

Race

Street Address

City

State

Zip Code

Contact Number (Cell Preferred- No dashes between numbers)

Driver's License State of Issuance

Driver's License Number

Email Address

Class Date

Select the day class begins.

Type of Service Requested

Risk Reduction (20-hours)

List charge(s) & county of arrest in box below.

Driver Improvement (6-hours)

List charge(s) & reason for class in comment section below.

Anger Management (10 weeks)

420-Marijuana (8-hours)

Victim Impact Panel (2-hours)

Consultation (15 minutes)

Shoplifting (10 weeks)

Parenting Class (10 weeks)

Charge(s) if applicable

(List all charges, i.e. number of DUI arrests in a lifetime, speeding tickets etc.)

City or County of Arrest

Date of Registration

Comments:

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