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Segment Two

Segment II Registration

Field name	Field
Full Name
Address	Address, line 1  Address, line 2    City/State/Zip
Home Phone	(Area code) Exchange - Number ext.
Cell Phone	(Area code) Exchange - Number ext.
DOB
E-Mail Address
Drivers Licenses #
Date Issued
Logged Driving Hrs (day)
Logged Driving Hrs (night)
Class Month	Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
Did you take Seg I with us?	Yes  No
Payment Info
We do not accept credit card payments. All Segment II payments will be made on the first day of class in the form of a check or cash only.

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