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.
April 13, 2019
May 11, 2019
June 8, 2019
July 13, 2019
August 10, 2019
September 14, 2019
October 12, 2019
November 9, 2019
December 14, 2019

Hennepin County Government Center Auditorium, 5:30 p.m. - 9:30 p.m.
April 30, 2019
May 28, 2019
June 25, 2019
July 30, 2019

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:_____________________________________________