LAKE LAND COLLEGE
TRAFFIC SAFETY
PROGRAM REGISTRATION FOR COLES COUNTY
Complete all fields in ink and print clearly. All fields are required in order to register.
If you were under 18 years of age when your ticket was issued, do not complete this registration form.
You must appear in court with a parent or guardian to request supervision.
Name:
Last First Middle
Mailing Address:
Apt.#:
City:
State:
Zip:
Cell Phone:
Previous Name(s): Gender:
Male Female
Home Phone:
Date of Birth:
MM/DD/YYYY
Email Address:
Driver’s License #:
CLASS OPTIONS
If you chose to avoid a conviction by taking the Defensive Driving Course, please check the best
day/time and location for your class.
Effingham Mattoon Charleston Sullivan Online*
Wednesday 6 p.m. - 10 p.m. Weeknights Weeknights Weeknights An additional
5 p.m. - 9 p.m. 5 p.m. - 9 p.m. 5 p.m. - 9 p.m.
$
4
0 fee applies to
complete this course.
(This fee will be billed to you
by Lake Land College.)
Saturday 8 a.m. - 12 p.m.
Other Location
Print name of state or county where class will be taken:
(Once your registration form is received by Lake Land College, you will receive information on how to register at another location.)
*If you were 18-20 years of age at the time of the violation you are not eligible for the online Traffic Safety School option
Are you in the United States on a visa-nonresident alien?
Yes in the United States on a visa - Provide home country of origin:
Not in the United States on a visa
Are you Hispanic or Latino
(or are you of Spanish origin)?
Yes
No
Are you from one or more of the following racial groups? (Select all that apply)
American Indian or Alaska Native Native Hawaiian or Other Pacific Islander
Asian White
Black or African American Choose not to respond
Highest Degree Completed:
Less than High School Certificate Masters Other
GED, year received _____ Associate Doctorate Some College
High School Diploma Baccalaureate 1st Professional Unknown
Please identify your primary racial/ethnic group. (Select one)
American Indian or Alaska Native Native Hawaiian or Pacific Islander
Asian White
Black or African American Choose not to respond
This information is for the sole purpose of Lake Land College.
OFFICE USE ONLY
Case Number: _______________________________ Citation Number: ________________________________
Citation Date: ________________________________ Termination Date: ________________________________
Amount Paid: ________________________________ Date Paid: _______________________________________
TRAFFIC SAFETY
READ THE REGISTRATION
INFORMATION BEFORE FILLING
OUT THE FORM ON THE RIGHT.
ELIGIBILITY GUIDELINES
You are eligible if you have not been placed on
court supervision for any other traffic violation
issued within 12 months (365 days) of this
violation.
You are eligible if the NO COURT APPEARANCE
REQUIRED box, located on the bottom portion
of your ticket, has been marked.
You are NOT eligible if you were under the age
of 18 at the time of the violation. You must
appear in court with a parent or legal guardian to
request supervision.
For additional information on Traffic Safety
class dates or the online course please
contact Lake Land College Traffic Safety
at 217-238-8258 or
trafficsafetypr[email protected].
Please do not contact the
Circuit Clerk’s office.
WHEN YOU RECEIVE A TRAFFIC
TICKET YOU HAVE FOUR OPTIONS:
1. PLEAD GUILTY ONLINE AND PAY ONLINE
Go to www.judici.com. If you choose this option,
stop here and follow the instructions online.
2. PLEAD GUILTY BY MAIL
Plead guilty using the appropriate copy of
your citation.
Pay cost of citation using a money order.
Follow the instruction on the citation issued
to you.
3. PLEAD NOT GUILTY BY MAIL AND
REQUEST A TRIAL
Plead not guilty using the appropriate copy
of your citation.
Do not appear in court until you receive a
court date.
4. APPLY FOR THE TRAFFIC SAFETY
PROGRAM BY MAIL
If eligible under the Eligibility Guidelines
shown herein, plead guilty and sign the “Plea
of Guilty with Court Supervision” form.
Complete registration form on right.
Send completed form and payment by
money order (citation cost and class fee)
to the circuit clerk.
Cost of citation -$164 for all complaints
The class fee is $50. If you
choose to complete the online
course, there is an additional $40
access fee code that will be billed to
you by Lake Land College.
Attend an approved 4-hour defensive driving
course within 120 days of the PLEA being
recorded.
You are granted 120 day court supervision
and must not receive a conviction for another
traffic ticket during that supervision.
To check on eligibility for court supervision,
please contact the Coles County Circuit Clerk’s
office.
State Issued:
Saturday 1 p.m. - 5 p.m.
County where ticket was received
BEFORE MAILING YOUR PAYMENT/
REGISTRATION
Make sure you print the information and it
can be easily read.
Make sure your money order is made out
to the clerk of the Circuit Court and it is
for the right amount.
If you wish to receive receipt, enclose a self-
addressed, stamped envelope.
When complete, tear it off, fold and mail in
an envelope to the Circuit Clerk’s office.
Your class information with the date, time
and location of the class will be mailed to
you by Lake Land College. If you do not
receive a class confirmation within four
weeks, it is your responsibility to contact
the Lake Land College Traffic Safety
Program.
If you cannot attend your assigned class,
immediately call Traffic Safety at
217-238-8258 or email
trafficsafetyprogram@
lakelandcollege.edu to reschedule. You are
allowed one reschedule at no cost. After
one reschedule, you will be charged $25 for
any additional classes that you reschedule.
If your mailing address changes, it is your
responsibility to notify the Lake Land
College Traffic Safety program. The school
is not responsible for late, lost and/or
undeliverable mail.
If you have a Commercial Driver’s License
(CDL), contact the Coles County State’s
Attorney’s Office.
PLEA OF GUILTY WITH COURT SUPERVISION
Read this portion carefully. Make sure you understand your responsibilities.
I am requesting that the court place me on supervision for the enclosed traffic violation. I was not
under the age of 18 on the date of the violation. It does not require me to appear in court.
I was not under the age of 18 on the date of the violation. If so, I have been approved by the
Court to complete the Traffic Safety Program.
I understand my Traffic Safety Program fee is non-refundable if I fail to complete the class or I am
found to be ineligible.
I understand that my supervision will last 120 days from the date the PLEA is recorded at the court
and it requires me to receive no other convictions for additional traffic violations during this time.
I have not been placed on court supervision for any traffic violation issued within 12 months (365
days) of the violation.
I understand that I am PLEADING GUILTY to the charge on this ticket, I WAIVE my right to a
hearing by the court or jury and request court supervision.
I agree to complete the Traffic Safety Program within 120 days from the date the PLEA is recorded.
I understand my supervision will be summarily revoked and my guilty plea will be used to enter a
conviction if:
I am found ineligible.
I do not complete the class within 120 days from the date the PLEA was recorded.
I receive another traffic violation within my supervision period.
I fail to return my certificate of completion from attendance of an out-of-area traffic safety
school to Lake Land College Traffic Safety Program, if applicable.
Signature: Date:
Printed Name:
