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

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.
August 5, 2014
September 2, 2014
October 7, 2014
December 2, 2014

Saturday, 8:30 a.m. - 12:30 p.m.
July 19, 2014
August 16, 2014
September 20, 2014
October 18, 2014
November 15, 2014
December 20, 2014

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:_________________________________________