DMA Registration Form
Purchaser Information
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
How did you find us?
*
Please Select
Someone's recommendation
Community Business Board
Flyer sent to my home
Social Media
If someone recommended you to DMA, please type their full name and relation to you below.
For example: "Erin Miller, my friend."
What is your relationship to the student?
*
If you are the student, please type "I am the student."
Student Information
Select one of the options below.
*
I am the Purchaser and the Student.
The Purchaser is not the Student.
Student's Full Name
Student's Phone Number
Student's Email
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Does the student have any prior driving experience?
*
Yes
No
Student's License Number
Student's License Expiration Date
License Class
G1
G2
G
Which BDE option would you like to sign up for?
*
Online
In-class, Sept 19, 20, 26, 27
Purchase
My Products
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next
( X )
Package 1
$522.00 CAD
$
522.00
CAD
Quantity
1
2
3
4
5
6
7
8
9
10
Package 2
$657.00 CAD
$
657.00
CAD
Quantity
1
2
3
4
5
6
7
8
9
10
Package 3
$787.50 CAD
$
787.50
CAD
Quantity
1
2
3
4
5
6
7
8
9
10
G2 Prep, Individual Lessons
$55.00 CAD
$
55.00
CAD
Quantity
1
2
3
4
5
6
7
8
9
10
G Prep, Individual Lessons
$60.00 CAD
$
60.00
CAD
Quantity
1
2
3
4
5
6
7
8
9
10
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Expiration Month
January
February
March
April
May
June
July
August
September
October
November
December
Expiration Month
Expiration Year
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
Expiration Year
Submit
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