Defensive Driving Student Contract
Please fill out the form in it's entirety. By submitting this form you are agreeing to all terms outlined in the contract below. Please call our office no later than Friday 5:00 pm to reserve your spot for the next class. Registration for this course will not be complete without full payment.
Full Name (as shown on Driver's License)
First Name
Middle Name
Last Name
Suffix
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Date of Birth
*
.
Month
.
Day
Year
DL #
*
Phone Number
*
-
Area Code
Phone Number
E-mail
*
Course Intent
*
Insurance Reduction
Points Reduction
Reinstatement
Pts Reduction/ Reinstatement
Other
Course Date
*
January 30, 21 (9 -4)
February 13, 21 (9-4)
February 20,2021 (9-4) virtual
February 27,2021 (9-4)
March 13,2021 (9-4)
March 27,2021 (9-4)
Upload a copy of student's Driver's License
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Defensive Driving Course
$
95.00
Processing Fee
$
5.00
Total
$
0.00
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