The Center for Cognitive Education, LLC.

2027 South 61stStreet, Suite #123 Temple, Texas, 76504

Fax 512-868-2644

Email: Web site:

DWI EDUCATION CLASSES

Temple Office Referral Form

DATE OF REFERRAL:______

CLIENT NAME/EMAIL/ PHONE NUMBER:______

______

CLIENT REFERRAL SOURCE NAME/TITLE: (e.g., Probation/Parole Officer, Assistant CoAttorney,etc)______

The Center for Cognitive Education offers programs/services with non-traditional hours (evenings/weekends). Programs/services listed are also offered in Bell, McLennan, Williamson,and Travis Counties. For additional information, please refer to our web site, , or send an email to .

Client’s: You MUST attend the Registration Session(listed below) to complete the enrollment process.

You must bring with you to the Registration Session your Referral Form, and a photo ID. Enrollment documents are completed during the ‘registration’ class.Following the ‘registration’, you must then attend all 3 scheduled class dates (listed below) in order to complete the program.

Instructions for the Referring Agency: Please mark the specific programlisted below and date that the client is being referred to. Provide the completed referral form to the client and instructions to be at the above Temple address on the date you specified. Client MUST attend the scheduled “Registration Session” that is held immediately before the actual class start date to complete enrollment documents.

  • Please email (or fax 512-868-2644) the completed referral form to the Class Facilitator, Reggie Rangel, . Advise client of program cost. Cash and/or money order, please. Checks are not accepted. Receipts will be provided upon payment and payment is due at time of the scheduled Registration date.

DWI Education Class details:

  • 3- day/12 hour, DHS Certifiedprogram.
  • Days to Attend: Wednesday, Thursday, and Friday.
  • Times of each day: Wednesday6:00pm - 10:00pm; Thursday 6:00pm – 10:00pm &Friday4:00pm - 8:00pm
  • Cost: $85.

2015 Registration Session and Class Dates:

  • January 7th, 5:30pm/ Class Dates: January 7,9,10.
  • February 4th, 5:30pm/ Class Dates: February 4,5,6.
  • March 4th, 5:30pm/ Class Dates: March 4,5,6.
  • April 8th, 5:30 PM/Class Dates: April 8,9,10
  • May 6th,5:30 PM/Class Dates: May 6,7,8
  • June 3rd, 5:30 PM/Class Dates: June 3,4,5
  • July 8th, 5:30 PM/Class Dates: July 8,9,10

DIRECTIONS:From Belton/Take Loop 363/57th Street Exit. Cross over bridge, turn left at light. Turn right on 61st Street. This is the street where the Bob Mills Furniture Store is located. Travel to the last office complex on your right, enter the parking lot. The complex is on the left about mid-way into the parking lot. Suite #123 is in the alcove of the building. From Loop 363 (Temple Mall area)/Take 57th Street exit. Stay on access road to light. Turn right on 61st Street. Follow above instructions...

DWI Education Program

  1. You have been court ordered to complete the following program in Temple, TX:

DWI Education Program: 12 hour state certified program.

Cost: $85 (payments must be made in full).

Location: 2027 South 61st Street, Suite #123, Temple, Texas, 76504

  1. Registration must be completed before you can be enrolled into the next class.
  1. You will need to complete and send the lower portion of this form along with your payment to The Center for Cognitive Education.
  1. Once registration is completed you will receive an email confirming your

enrollment into the program.

**Class registration fee will not be refunded if you fail to attend the scheduled class**

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Please complete and send this portion of the form back with your payment:

Name: ______

Email: ______@______

Address: ______

City: ______

Phone #: (____)______

I have enclosed a total of $_____ (Money Orders Only)

Pay to the order of: The Center for Cognitive Education

Questions:

(Subject Line must contain: DWI ED-Temple