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For Office Use ONLY: date received:_______________ copied:______ paid:____________ cash / check#____________ receipt#____________ ______________________________________________________________________________ First Middle Last
Birth Date:____/____/____
_______________________________________________________________________ Hm. Phone:(____)_________ Cell Phone:(____)_________ E-mail address:______________________@_____________ What school do you attend?_______________________________________________ How did you hear about this course?__________________ From whom?____________ What course are you interested in? Date:_________________ Time:______________ Check the class location: ____ Burton ____ Swartz Creek
Method of Payment
Refund Policy
Course Work In order to begin Segment 2 class work, the student must present proof of completion of Segment 1. The parent or guardian certifies that the student has completed 30 hours of supervised driving which included at least 2 hours of supervised night driving and has successfully completed Segment 1 of an approved Driver Education course at least 3 months prior to the start of Segment 2 class work.
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_________________________ ______________________ Notice Statement: "This school is required to be licensed by the Michigan Department of State, Driver Training & Testing Programs. If you have a complaint which you cannot settle with this school, write: Michigan Department of State, Driver Training & Testing Programs, Lansing, MI 48918. Completion of driver training instruction does not guarantee qualification for a driver license." |
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