Registration

Date: 09/04/2010

After reviewing the policy, I hereby give permission for my son/daughter to take driver education as offered by Benson's Driving School, LLC.

Student name (Print full name as it appears on birth certificate):

Sex:
Male Female

Date of birth (mm/dd/yyyy):

To the best of my knowledge, my son/daughter has no physical or mental problems that would interfere with the safe operation of an automobile. Finally, I understand that an employee, so designated by Benson's Driving School, LLC, may ask for a professional evaluation if they feel such an evaluation is warranted.

Per recommendation of the NH Department of Safety, please answer the following questions:

1. Are the driving privileges (not license) for the person enrolling in this driver education program currently under suspension or revocation?
   Yes No
2. Is there any pending action against the person enrolling in this driver education program which would cause the driving privileges to be suspended or revoked in the future?
   Yes No
3. Should the driving privileges of the person enrolled in this driver education program become suspended or revoked during enrollment for any reason, we will report it to the driving school administrator immediately?
   Yes No

Session requested: 01/17/2011

Parent or legal guardian:

Address:

Telephone number:

E-mail:

Referred by:

If you register today, a seat will be held for five days pending receipt of permission form and deposit.

By submitting this form, you agree to all terms of the policy.

Important note: you must submit this form (by actually clicking the button) in order to register. After the form has been submitted, you will be asked to print, sign, and send a confirmation page.