Student Information
Name:
Please do not use an apostrophe (') in your name. (For example, please enter O'Neal as ONeal.)
 
First    Middle    Last    Suffix
Date of Birth (mm/dd/yyyy): / /
Driver License Number:
Gender:  Male Female
Address:

Street

City    State    Zip Code
Phone Number:  ( ) -
 
E-mail Address:
Payment Information
Price: $13.95
Credit Cardholder's Name:
Billing Address (as it appears on your credit card)
Click here if same as address above

Street

City    State    Zip code
Credit Card Type:    Credit Card Number:
 
Expiration Date: /    CVV2 Code: What is this?
Student Validation Questions
These questions will be randomly asked during the course to verify your identity.
1. Have you previously taken an insurance discount course? yes no
2. Is a member of your family unable to drive due to health/medical reasons? yes no
3. Have you ever received a traffic citation? yes no
4. Do you enjoy driving? yes no
5. Do you consider yourself to be a safe driver? yes no
6. Have you been the driver of a vehicle involved in a crash? yes no
7. Have you known anyone who was killed in a vehicle crash? yes no
8. Have you been involved in a traffic crash where the air bag(s) deployed? yes no
9. Do you know anyone who drives while impaired by alcohol or drugs? yes no
10. Do you know anyone who texts while driving? yes no
I hereby certify that I will be the only person taking this course.
Please let us know how you heard about us.
Florida Department of Highway Safety and Motor Vehicles website (www.flhsmv.gov)
Email from Wise Traffic School
Friend or Family Member
Other