Only fill out this form if you completed your driver's education course between August 2004 and May 2010
Please Verify ALL Fields Before Pressing Submit.
You Will NOT Be Able To Make Changes Once You Press Submit
Enter Your Information Below
   
Student Last Name*
Student First Name*
Student Date of Birth* Click button to show date picker
enter date in  mm/dd/yyyy format
Student or Parent Phone Number*
Student or Parent Email Address*
Verify Your Email Address*
Home School*
If You Selected Other / My School Is Not Listed,
Please Enter Your School Name Here
Student Number*
Driver's Education Site Attended*
Approximate Date Student Finished Course* Click button to show date picker
enter date in mm/dd/yyyy format
* This Field is Required
Please Verify ALL Fields Before Pressing Submit.
You Will NOT Be Able To Make Changes Once You Press Submit
     
   

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600 SE Third Ave. Fort Lauderdale, FL 33301 USA
Phone: (754) 321-0000