Allstate Driving Instruction Application

Allstate Driving Instruction Application
375 Notch Road
Mendon, VT 05701
allstatevt1@gmail.com
www.allstatevt.com
Full Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Class Location & Type:*
High School Name:*
Permit#*
Permit Issue Date*

MonthDayYear
Phone:*
Format: (000) 000-0000.
E-mail:*
Parents/Guardians Email: (Under 18)
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact:
Emergency Contact Phone:
Format: (000) 000-0000.
List relevant physical / medical conditions:
List all relevant learning challenges:
Regarding learning challenges:

Other than above, I certify that I have no conditions that may place myself or others at risk of injury.
Review Allstate Driving Instruction Policy Manual:
Allstate Driving Instruction Policy Manual*

I have read and understood the Allstate Policy Manual.
Review Allstate Driving Instruction Release / Waiver:
Allstate Driving Instruction Release / Waiver*

I have read and understood the Allstate Release / Waiver.
Applicant Full Name:*
Application Signature:*
Date*

MonthDayYear
Parent / Guardian Full Name:
(For 18 & Younger)
Parent / Guardian Signature:
Date

MonthDayYear
Please submit your deposit/payment via Venmo: @tejaldholakia (9234)
Please verify that you are human*
Should be Empty: