Minnesota Safety Council: Court-Referred Defensive Driving Course Registration Form

Print this form and mail or fax it in at least one week prior to class.

Court-Referred Defensive Driving Course Registration Form

Three ways to register:
Mail: MN Safety Council 474 Concordia Ave St. Paul, MN 55103	Phone: 651-228-7332 or 800-444-9150, ext. 332	Fax: 651-291-7584

Name:_______________________________________________________

Address:_____________________________________________________

City, State, Zip:________________________________________________

Phone:_________________Drivers License Number____________________

E-mail Address:_______________________________________________

Class location/date choice:
Saint Paul, 8:00 a.m. - 12:30 p.m.
February 11, 2012
March 10, 2012
April 14, 2012

Crystal, 5:30 p.m. - 10:00 p.m.
February 28, 2012
March 27, 2012
April 24, 2012

Tuition fee: $65.00 (non-refundable)

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:_____________________________________________