Read the Registration Information before filling out this form
When complete, mail it to Coles County Circuit Clerk’s Office, 651 Jackson Ave, Room 128, Charleston, IL 61920.
Keep the top of this form for your information.
Your class confirmation 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 Traffic Safety.
If you cannot attend your assigned class, immediately call Traffic Safety at 217-234-5467 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), the Traffic Safety Program will not prevent action against your CDL.
Coles County Traffic Safety Program Registration Form
If you were under 18 years of age when your ticket was issued, do not complete this registration form. You must attend court in
person with a parent or guardian to request supervision.
Name: _____________________________________________________ ____________________________ _______________
Last First Middle
Previous names (s) _________________________________Address:____________________________________________________
City/State/Zip Code/County: ____________________________________________________________________________________
City State Zip code County
Telephone: ______________________________ ______________________________ Gender: ____ Male ____ Female
Home Cell
Birthdate: _______/________/__________ E-Mail Address: ________________________________________________
MM DD YYYY
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 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
Please identify your primary racial/ethnic group. (Select One).
American Indian or Alaska Native Native Hawaiian or Other Pacific Islander
Asian White
Black or African American Choose Not to Respond
Hispanic or Latino
Highest degree completed:
_____Less than High School _____Certificate _____Masters _____Other
_____GED, year received _____ _____Associate _____Doctorate _____Some College
_____High School diploma _____Baccalaureate _____1
st
Professional _____Unknown
Drivers License Number: ___________________________________________________ Issuing State of Drivers License: _______
If you chose to avoid a conviction by taking a Defensive Driving Course, circle the best day/time and location for your class?
Effingham (only) Mattoon (only) Charleston (only) Sullivan (only) Online
Wednesday 6:00-10:00 p.m. Weeknights Weeknights Weeknights An additional $35 fee
Saturday 8:00 a.m-12:00 p.m. 5:00-9:00p.m. 5:00–9:00 p.m. 5:00–9:00 p.m. applies to complete this course.
Saturday 1:00-5:00 p.m. (This fee will be billed to you
by Lake Land College.)
Other Location - Print name of State or County where class will be taken _________State_________________________ County
(Once your registration form is received by Lake Land College, you will receive information on how to register at another location.)
For additional information on class dates or the online course please contact Lake Land College Traffic Safety at 217-234-5467or
trafficsafetyprogram@lakeland.cc.il.us. Please do not contact the Coles County Circuit Clerk’s office.
Office Use Only:
Date Enrolled: _________________ Term Date: ____________________ Case Number #: __________________
REV 13-2/14
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 18 years of age at the time your ticket was issued. You must appear in court with a
parent or legal guardian to request supervision.
When you receive a traffic ticket you have four options:
1. TO ENTER A PLEA OF 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 instructions on the back side of the blue copy of 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 notice of court date.
4. APPLY FOR THE TRAFFIC SAFETY PROGRAM BY MAIL
If eligible under the Eligibility Guidelines shown herein, plead guilty and sign below.
Complete registration form on reverse.
Send completed form and payment by money order (citation cost and class fee) to the Circuit Clerk in the envelope provided.
o Cost of citation - $120 for all complaints, except $140 for speeding more than 20 mph but not more than 30 mph
over the limit.
o The class fee is $40. If you choose to complete the online course, there is an additional $35 access code fee 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 entered.
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 judicial supervision, please contact the Coles County State’s Attorney’s office at 217-348-0561.
“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. It does not require me to appear in court.
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 other 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:
o I am found to be ineligible.
o I don’t complete the class within 120 days from the date of the PLEA.
o I receive another traffic violation within my supervision period.
o 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___________________________________
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.
Make sure you have an envelope for the return of your receipt, driver’s license and/or bond card.
Citation Date: _________________ Citation Number: _______________
