|
Date
of Birth |
Month | Day | Year |
Select
One Course Type
|
Internet | |
|
|
19 |
 |
 |
PRE-REGISTRATION |
PLEASE PRINT WITH DARK INK |
| Student is registering into two (2) independent/home study Programs: |
No refunds once submitted |
| 1) Driver Education & 2) Drug and Alcohol Awareness |
|
|
Program 2 may be substituted by PEN |
|
| STUDENT INFORMATION |
|
Student's First Name |
|
Middle name |
|
Last Name |
|
|
Date
of Birth |
Month | Day | Year |
Select
One Course Type
|
Internet | |
|
|
19 |
|
|
| Address |
Apt. No. |
| City | State | Zip Code |
|
Phone ( ) |
Email Address |
| Student's School |
Grade Level |
| List all Disabilities |
| The parent/guardian signing this application certifies, under penalty of perjury that: |
|
1. parent/guardian has custody of applicant named on this form and consents to the enrollment and participation of applicant in Driver Education and Drug & Alcohol Awareness programs, |
|
2. parent/guardian will proctor and monitor exams to the applicant. The applicant will take these exams personally and without assistance of any type (books, notes, person, etc.), |
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3. I agree to all terms, rules and procedures that I have read on the Driver Education Home Study Information page. |
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4. any or all information may be disclosed and/or tracked for studies and/or audits pertaining to the effectiveness and compliance of home schooling Driver Education. |
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5. all statements made on this form are true and correct. |
| PARENT/GUARDIAN INFORMATION |
|
FULL NAME
|
CHECK
ONE |
PARENT |
GUARDIAN |
|
|
|
|
CA LICENSE NUMBER |
EXPIRATION
DATE |
MONTH | DAY | YEAR | |
|
SIGNA- TURE |
TODAY'S
DATE |
MONTH | DAY | YEAR |
|
IF
PAYING BY CREDIT CARD SELECT ONE |
VISA |
MASTERCARD |
CARD NUMBER |
|
|
|
|
NAME ON CARD |
EXPIRATION
DATE |
MONTH | YEAR |
|
my signature authorizes private educational network (a.k.a. penschool) to deduct a non-refundable $110 (ONE- HUNDRED TEN dollars) from my credit card indicated above. this payment is for tuition. certification is contingent on student successfully passing the above courses. |
|
SIGNATURE
|
TODAY'S
DATE |
MONTH | DAY | YEAR |
| FOR FASTER PROCESSING, PRE-REGISTRATION PAID BY CREDIT CARD MAY BE FAXED TO (408) 549-9912 |
MAIL
THIS PRE-REGISTRATION WITH CREDIT CARD INFORMATION COMPLETED OR A $110
CHECK OR MONEY ORDER TO
|
PEN 408-280-1122 |
| 350 W. Julian Street, Bldg. 5 | ||
| San Jose, CA 95110-2305 |
