Registration: Driver Improvement Clinic - Classroom

Do not take this course if you failed the DMV written test 3x and need to take a course before taking the DMV written test again

FIRST NAME *

MIDDLE NAME *

LAST NAME *

STREET *

CITY *

STATE *

ZIP *

PHONE *

DATE OF BIRTH *

VA LICENSE OR ID # *

EMAIL ADDRESS

REASON FOR TAKING THE COURSE *

	DMV (On your VA DMV compliance or from correspondence from the VA DMV that you need to take a Driver Improvement Clinic)
	Insurance (Please contact your car insurance provider before taking this course)
	Court ordered WITHOUT safe driving points (If you do not have any documentation from the Court stating that you will get safe driving points, then choose this option)
	Court ordered with safe driving points (If you have documentation from the Court stating that you will get safe driving points and can present the document the day of the class, then choose this option)
	Voluntary (Upon successful completion, you will receive 5 Safe Driving Points)

WHICH CLASS DO YOU WANT TO SIGN UP FOR? *

All classes are on a Saturday, from 8:30AM-5:00PM, please arrive 15 early and bring a lunch.

PRICE:
$ 65.00

COUPON CODE:

METHOD OF PAYMENT:

Pay online through Paypal (preferred)

Pay in person at 4625 West Broad Street

Pay over the phone by calling 804-918-6634

I hereby verify that the information on this registration form is accurate. By signing, I am agreeing that Drive-To-Work and DTW Driving School may use my first name (only) and my photograph for any materials published.)

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