2. Today's Date:*
   Today's Date:
3. Citation No.*
5. First Name*
6. Last Name*
8. Date of Birth*
   Date of Birth
10. Address1*
12. Address2
14. City*
15. State*
16. Zip*
18. Phone number*
19. Phone is*

    1. Home
    2. Cell
20. Email*
22. After completing the above, please READ and ELECTRONICALLY SIGN, below.
24. I certify and declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct.
26. Electronic Signature Agreement*

    1. I agree. Electronic Signature.

    By checking the "I agree" box above, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
27. Electronic Signature of Defendant*
    Last name, first name, middle initial
29. Date signed:*
    Date signed:
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31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit Submit and Print

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