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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
    July 21, 2016
    August 18, 2016
    September 15, 2016
    October 20, 2016
    November 17, 2016
    December 15, 2016
4th Saturday of the Month, 8:30am - 12:30pm
    August 27, 2016
    September 24, 2016
    October 22, 2016

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_____/_____

Name on Card:_________________________________________