Valentine’s Driving School Inc.
Adult Online Application / Registration Information
Age Group: 18-20 _____21-30 _____31-40 _____41-50_____51-60 _____61 +
Highest Education:
Name and Location of Highest
School___________________________________________________________
Highest Grade Completed _____________ Year Graduated ________________
Professional Development:
_____ Adult Drivers Education Program
_____ Driver Improvement Program _____ Road Evaluation
Preference Available:
Days: ____ Mon ____ Tues. ____ Wed. ____ Thurs. ____ Fri. ____ Sat.
____ Sun.
Times: _____ AM ________________________ to _______________________
PM ___________________________ to __________________________
Evening’s ________________________ to __________________________
Name___________________________________________________________
Driver License Number______________________________
Expiration______________
Phone (H) _______________ (W) _______________ (Cell) ________________
Email Address_________________________________________________________
Address_________________________________________________________
City________________________ State__________________
Zip__________________
Date of
Money Order______________ Travelers Check ________________________
PO # ____________________________Company________________________
If special assistance is required, please describe
________________________________________________________________
Course # Course Title Date Tuition
________ __________________________ _____________ ______________
________ __________________________ _____________ ______________
________ __________________________ _____________ _____________
Tax 4.712% $________________
Total Amount Due $ ____________
Make-Up Sessions: If unable to attend any scheduled Instruction Student must call Instructor two hours before scheduled instruction appointment. Student will be responsible for make-up session charge of $40.00 per session. Make-up charge must be paid in cash before the next schedule instruction session.
I agree with the above information and with Valentine’s Driving School Inc. policy and rules. Please feel free to visit our web site at www.valentinesdrivingschoolinc.com
Student Signature:_________________________________________ Date___________
Parent Signature:__________________________________________ Date___________
Parent Signature:__________________________________________ Date___________