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2. Date
   Date
4. **This information MAY or MAY NOT be available at the time requested or MAY NOT be available for PUBLIC INSPECTION.
6. First Name*
7. Last Name*
9. Representing Firm or Company Name
10. Email Address
12. Address*
14. City*
15. State*
16. Zip Code*
18. Phone Number*
19. Fax Number
21. Driver's License #*
22. State License Held*
24. Location of Accident*
26. Description of Offense Report(s) or Public Record(s) being requested, Please include any dates of Offense, Names, and Dates of birth of persons involved in Offense(s):
28. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
30. Electronic Signature

32. If you have any questions concerning this form or required payment of requested items, please contact The Department Administrative Assistant at 979-798-2195 ext 313.

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34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit Submit and Print

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