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Alive at 25 Defensive Driving Course
Registration Form
Three ways to register:
Mail: Minnesota 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: ____________________________________________

E-mail Address: _______________________________________

Court Referred Yes No     County Referred by: ____________________

Tuition fee: $65.00 (non-refundable)
Location: Minnesota Safety Council, 474 Concordia Ave, St. Paul, MN 55103

Class date/time choice:
      Thursday, November 15, 2018 | 5:30 - 9:30 p.m.     Saturday, November 17, 2018 | 8:30 a.m. - 12:30 p.m.
      Thursday, December 20, 2018 | 5:30 - 9:30 p.m.     Saturday, December 15, 2018 | 8:30 a.m. - 12:30 p.m.
      Thursday, January 19, 2019 | 5:30 - 9:30 p.m.     Saturday, January 17, 2019 | 8:30 a.m. - 12:30 p.m.
      Thursday, February 16, 2019 | 5:30 - 9:30 p.m.     Saturday, February 21, 2019 | 8:30 a.m. - 12:30 p.m.
      Thursday, March 16, 2019 | 5:30 - 9:30 p.m.     Saturday, March 21, 2019 | 8:30 a.m. - 12:30 p.m.
      Thursday, April 18, 2019 | 5:30 - 9:30 p.m.     Saturday, April 20, 2019 | 8:30 a.m. - 12:30 p.m.

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:_____________________________________________