Registration Form- Refresher Course

Motorcycle Training Course
Refresher Course Registration Form

( Waiver of Claim Form must accompany registration )

Refresher Course Location: (check one)		Belleville-$279.00		Peterborough-$309.00
Refresher Course Location: (check one)

Course Date:

Preferred

____/____/____

Alternate

____/____/____

Name:

_____________________________________________

Address:

_____________________________________________

City:

_____________________________________________

Postal Code:

______-______

Telephone:

Day_____________________ Night____________________

Date of Birth:

___________________________

Method of Payment

Cheque

Visa

MasterCard

Money Order

Card Number:

__________-__________-__________-__________

Expiry Date:

____/____
(month/year)

Signature:

_____________________________________________

Date:

____/____/____

Print out this form and the Waiver of Claim Form and then choose your method of registration - Telephone - Mail - Fax.

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