INCLUSIVE DRIVING SCHOOL OF HALIFAX - REGISTRATION FORM

(PLEASE PRINT CLEARLY)

Course No.________________________Start Date _________/_________/______ D.O.B. / /

Year Month Day Year Month Day
Mr. Ms. Surname _______________________ First Name_______________________ Initial _______ M / F
Mrs. Miss
Address: ____________________________________________________________________________________
Number Street Apt City Province Postal Code
Res Tel: __________________ Cell: ______________________ E-mail:___________________
Learner’s Permit No. _______________ Issue Date _____/_____/_____Expiry Date______/_____/___
( If available) Year Month Day Year Month Day

Payment Method Cheque Cash Amount Authorized $_______________ (Tax included)

_____________________________________________________________________________________________
Enclose in envelope with cheque and mail to: 24 Adelaide Ave. B3N 2N4 Halifax NS
Tel: (902) 401-1338 / 446-0122
Info@inclusivedrivingschool.ca

STUDENT CERTIFICATE#: E