Complete this form to make an additional classroom payment! Classroom Location*Class Start Date and Time*Student's Full Legal Name* First Middle Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone Number*Parent's Names*Email* Enter Email Confirm Email Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code High School Student Attends*Payment*(If $50 down payment) Remainder $170.00(If $100 down payment) RemainderPayment $120.00Total $0.00 Credit Card DiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name Requirements*Agree1. This contract expires 2 years from the first day of classroom training. All classes and BTW lessons must be completed before the expiration date. Any refund must be requested in writing before the expiration date. 2. If you choose to break up the classroom and BTW payment, the BTW portion will be billed at the rate current for that time. 3. The first BTW lesson must be completed within the first four months from the date the student received their permit. 4. You can only schedule 1 BTW lesson at a time and the student should practice for at least 1 month between lessons. REFUND POLICY: Registrations that are cancelled less than 7 days prior to the class start date are subject to a cancellation fee of $25. Cancellations more than 7 days from the class start date, will be refunded in full less a $10 fee for credit card refund processing fee.