Date __________________ I, the undersigned,
for good and valuable consideration hereby waive a hearing in court
and plead guilty to the traffic violation as charged on the reverse
side hereof, and duly constitute the Clerk of the City Court or ___________________,
my attorney, and authorize him to appear in court, enter my plea and
pay my fine which is enclosed herewith.
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This is my ____________ offense for this violation
within the current calendar year.
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Name ___________ Motor Vehicle License No. __________
Address __________ Operator's License No. _____________
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