Print this form and mail or fax it in. Please print or type.

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 21, 2016
    February 18, 2016
    March 17, 2016
    April 21, 2016
4th Saturday of the Month, 8:30am - 12:30pm
    January 23, 2016
    February 27, 2016
    April 23, 2016
    June 25, 2016
    July 23, 2016
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:_________________________________________