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: 651-228-7308 or
800-444-9150, ext. 308
Fax: 651-291-7584

Name:_______________________________________________________

Address:_____________________________________________________

City, State, Zip:________________________________________________

Phone:_________________________________

E-mail Address:_______________________________________________

Class location/date choice:
Saint Paul, 8:30 a.m. - 12:30 p.m.
    May 13, 2017
    June 10, 2017
    July 8, 2017

Crystal, 5:30 p.m. - 9:30 p.m.
    May 23, 2017
    June 27, 2017
    July 25, 2017

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:_____________________________________________