No.

__________ Date:_____________
NAME:________________________________________________________AGE:_________ _
ADDRESS:_____________________________________________________________
LICENSE/IDENTIFICATION NO.__________________________DATE:_____________________ Not
Confiscated Not Confiscated VIOLATION/S o Illegal Parking o Obstruction o Over Speeding o Disregarding
Traffic Signs o Reckless Driving o Driving with invalid/delinquent Driver’s License o Overloading o No
Franchise/Colorum o Unregistered motor vehicle/no plates o Arrogance or discourtesy o Loading or
unloading in prohibited zone Date and time of violation:_____________________ Owner of
Vehicle:_____________________________ Vehicle Registration No.:_____________________ Plate
No.:__________________ Type of Vehicle: __________________________ Insurance Policy
No.:___________ OFFENSE: First Second Third Fourth You are hereby directed to report to Municipal
Treasurer’s Office within 72 hours from date hereof for disposition of proper action.
___________________ Apprehending Officer I hereby promise to appear at the Municipal Treasurer’s
Office within 72 hours to answer the above-described charge(s). ___________________ Signature of
Violator No.:_________