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-hour Course

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

Driver Improvement 6-hour Course

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

Family Violence Intervention Program

Anger Management

420-Marijuana

Victim Impact Panel

Consultation

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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