SOUTHERN ILLINOIS DRIVING SCHOOL

REGISTRATION/CONTRACT ACCEPTANCE FORM

PLEASE PRINT

TODAY'S DATE

Student

Student's First Legal Name

Middle Legal Name

Last Legal Name

Street Mailing Address

Phone

City

State

Zip

Birth Date

Sex

Male Female

Email Address

Student Driver’s License or Illinois State ID #

Please indicate if your license is “Suspended” (Yes or No) or Court Ordered (Yes or No)

Suspended Yes No

Court Ordered Yes No

What is the reason you have to take this class “Be Specific – Tickets”:

Other Information:

Student Signature (type your full name)

Date

When you are done, print it, save a copy, or email it to the school ahead of time.