Minnesota Safety Council
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Alive at 25 Defensive Driving Course
Registration Form
Three ways to register:
Mail: Minnesota Safety Council
474 Concordia Ave
St. Paul, MN 55103
Phone: 651-228-7302
800-444-9150
Fax: 651-291-7584

Name: _________________________________________________________

Address: ____________________________________________________

City, State, Zip: _____________________________________________

Phone: ____________ Drivers License Number____________________

Court Referred Yes No

County Referred by: _____________________________________________

Class date choice:
3rd Thursday of the Month, 5:30pm - 9:30pm
January 15, 2015
February 19, 201
March 19, 2015
April 16, 2015
May 21, 2015
June 18, 2015
July 16, 2015
August 20, 2015
September 17, 2015
4th Saturday of the Month, 8:30am - 12:30pm
January 24, 2015
February 28, 2015
March 28, 2015
April 25, 2015
June 27, 2015
July 25, 2015
August 22, 2015
September 26, 2015
October 24, 2015
Tuition fee: $65.00 (non-refundable)
Location: Minnesota Safety Council Annex, 474 Concordia Ave, St. Paul, MN 55103

Payment must be received with registration one week prior to class
Money order or credit card ONLY—no checks accepted
Money Order Visa MasterCard American Express

Card Number:______________________Exp. Date_____/_____

Name on Card:_________________________________________