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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____________________

E-mail Address: _______________________________________

Court Referred Yes No     County Referred by: ____________________

Class date choice:
3rd Thursday of the Month, 5:30pm - 9:30pm
    December 15, 2016
    January 19, 2017
    February 16, 2017
    March 16, 2017
4th Saturday of the Month, 8:30am - 12:30pm
    December 17, 2016
    January 28, 2017
    February 25, 2017
    March 25, 2017

Tuition fee: $65.00 (non-refundable)
Location: Minnesota Safety Council, 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: _____/_____ CVV2 Code: ________

Name on Card:_____________________________________________