Registration Form: Point System Conference, Driver Improvement Program

Personal Information
First Name:
Middle Name
Last Name:
Address:
Address 2:
City:
State:
Zip:
Phone Number: xxx xxx xxxx
Evening Phone Number: xxx xxx xxxx
Email Address:
Re-enter Email Address:
License Number:
Date of Birth: mm/dd/yyyy

Course Information

 

Student is registering for:

 TWO HOURS OF BEHIND THE WHEEL DRIVING($50 PER HOUR) SPECAL PRICE FOR DIP STUDENTS ONLY $100.00
DRIVERS IMPROVEMENT PROGRAM 9am-5pm(this includes time for a lunchbreak) $80.00
Date & Location of Course:
Date of MVA Letter:
MVA due date for course:



Payment Information
Cost Total: $
Charge Type: VISA
MASTERCARD
DISCOVER
AMERICAN EXPRESS
Card Number:
Expiration Date: (MM/YYYY)
Cardholder Name
CVV2 For AMERICAN EXPRESS enter the 4 numbers on the front top right corner. For all other cards, please enter the last 3 numbers on the back side of your card.

Policies
By initialing below, I agree to the following EASY METHOD DRIVING SCHOOL policies:

*Student is required to arrive on time, stay for the entire course and pass the tests.

*Student must provide EMDS with his/her driver's license number. If the student does not provide the number, EASY METHOD DRIVING SCHOOL cannot notify the MVA that the student has completed the course. The student agrees that EASY METHOD DRIVING SCHOOL will not be responsible if his/her license is suspended for non-completion of required course.

*Student must present MVA letter to EASY METHOD DRIVING SCHOOL for verification that he/she is taking the correct course. If the student does not present the letter, the student agrees that EASY METHOD DRIVING SCHOOL will not be responsible if their license is suspended for not completing the correct course.

I agree: Student's Initials.