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For Office Use ONLY: date received:_______________ copied:______
paid:____________ cash / check#____________ receipt#____________
First Middle Last
Hm. Phone:(____)_________ Cell Phone:(____)_________
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
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.
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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