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.
    November 11, 2017
    December 9, 2017
    January 13, 2018

Crystal, 5:30 p.m. - 9:30 p.m.
    November 28, 2017
    January 23, 2018
    February 27, 2018

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:_____________________________________________