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): / /
Social Security Number (last 4 digits):
Gender:  Male Female
Address:

Street

City    State    Zip Code
Phone Number:  ( ) -
 
E-mail Address:
Payment Information
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Refund requests will be considered on a case-by-case basis.
Price: $15.00
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. Do you have two or more tattoos? yes no
2. Have you been a member of a club at school? yes no
3. Do you have a B or better grade point average at school? yes no
4. Have you ever had braces? yes no
5. Do you own a pet? yes no
6. Have you been an occupant in a vehicle involved in a traffic crash? yes no
7. Have you known anyone who was killed in a traffic crash? yes no
8. Have you been involved in a traffic crash where the air bag deployed? yes no
9. Do you know anyone who has driven while impaired? 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.
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Florida Department of Highway Safety and Motor Vehicles website (www.flhsmv.gov)
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