Minnesota Safety Council
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Ramsey County Referral Program
Alive at 25 Defensive Driving Course
Registration Form
Three ways to register:
Mail: MN 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____________________

Tuition fee: $85.00 (non-refundable)
Location: Minnesota Safety Council Annex, 474 Concordia Ave, St. Paul, MN 55103

Class date choice:
Tuesday, 5:30 - 9:30 p.m.
March 3, 2015
April 7, 2015
May 5, 2015
June 2, 2015
July 7, 2015
August 4, 2015
September 1, 2015
October 6, 2015
December 1, 2015

Saturday, 8:30 a.m. - 12:30 p.m.
February 21, 2015
March 21, 2015
April 18, 2015
May 16, 2015
June 20, 2015
July 18, 2015
August 15, 2015
September 19, 2015
October 17, 2015
November 21, 2015
December 19, 2015

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:_________________________________________