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2. First Name*
3. Last Name*
5. Phone Number*
6. Email Address
8. Mailing Address*

   Mailing Address/ City/ State/ ZIP

10. Mitigation Request*

    1. Requesting reduction of traffic penalty
    2. Requesting Deferred Finding
11. For Deferred Finding Request:*

    1. I do not have a CDL
    2. I have not had a Deferred Finding in the last 7 years.

    (Check all that apply)

13. Statement by Requestor*
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15. 1. Receive an email copy of this form.
16. Email address

    This field is not part of the form submission.

17. Submit Submit and Print

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