This application may be used for disposition of a traffic infraction - NOT TO BE USED FOR MISDEMEANORS OR 3RD OR SUBSEQUENT SPEED VIOLATIONS IN 18 MONTHS.
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Submit this form to the Court by Certified Mail.   If the Court denies this application, the applicant will be notified to appear.

I, _______________________________ residing at ____________________________________________________, have been charged with_____________________________________________ VTL and acknowledge receipt of the warning  "A plea of Guilty to this charge is equivalent to a conviction after trial. If you are convicted, not only will you be liable to a penalty, but in addition your license to drive a motor vehicle or motorcycle, and your certificate of registration, if any, are subject to suspension and revocation as prescribed by law"; and I waive arraignment in open court and the aid of counsel. I PLEAD GUILTY to the offense as charged and request that this charge be disposed of and penalty fixed by the Court. During the last 18 months I have been convicted of those violations marked on my attached conviction stub.

I make the following statement of explanation
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DATE: __________________ SIGNED: _________________________________________
 

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

I hereby plead Not Guilty to the charge of
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DATE: __________________ SIGNED: ________________________________________

ADDRESS: _________________________________________________________________

NOTE: Mail to the Court specified by Certified Mail within 48 hours. The Court shall advise the violator of the trial date.

Applicants under 18 years of age must submit Name and Address of Parent or Guardian below:

_______________________________

________________________________________________________________________________
Name of Parent or Guardian                        Address
 

RETURN FORM TO:          Elmira City Court
                                            317 E. Church Street
                                            Elmira, New York  14901
 

TO PAY BY CREDIT CARD (VISA OR MASTERCARD ONLY) CARDHOLDER MUST FILL IN THE FOLLOWING. I AGREE TO PAY THE TOTAL AMOUNT ABOVE ACCORDING TO THE FINE SET BY ELMIRA CITY COURT.

CARD TYPE: ____VISA ____MASTERCARD CARD #:________________EXP DATE:__________
 

                                                                                              *
________________________________________                    _______________________________
PRINT NAME AS ISSUED ON CARD                                     SIGNATURE OF CARD HOLDER

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TELEPHONE NUMBER OF CARD HOLDER

*  If other than the defendant, submit a clear photocopy of photo ID with signature (i.e. drivers license)