AAA Driver Improvement Program

AAA DIP Lead Instructor Certification and Recertification Workshop REGISTRATION

Please mail this registration form with payment information, motor vehicle record and club approval letter to AAA National Office MS 33, Driver Training Operations, 1000 AAA Drive, Heathrow, Fl. 32746. For your convenience, only credit card payments for class fees are accepted (Visa, MasterCard or Discover). Reservations are accepted on a first-come, first-served basis for scheduling purposes. We will contact participants to confirm course reservation and provide information on area accommodations and directions. Each workshop is limited to a maximum of 16 participants and may be canceled due to low enrollment. Incomplete registrations will not be processed. Please send all documents at one time to reserve your spot in the course.

WORKSHOP DATES and LOCATION Price

Date: August 18 – 21, 2014 Club $480.00

Public $515.00

Location: 1305 Sacramento Street

Redding, CA 96001

Note: Non-refundable payment must be received by 07/01/14

PLEASE COMPLETE AND SIGN

In registering for the above workshop, the information provided below authorizes the AAA National Office to obtain my motor vehicle record (MVR) to review for eligibility to participate in the AAA Driver Improvement Program Leader Certification Workshop should you not submit an MVR. Please note that all participants are required to submit a current MVR to the AAA National Office prior to attending the class. (*required fields)

Last Name*: / First Name*: / MI:
Organization*:
Address*:
City*: / State*: / Zip*:
Email*:
Work phone #*: / Home phone #: / () / Fax #: / ()
Date of birth:
Please provide the payment information requested below (all required).
Circle one: / Visa / MasterCard / Discover
Card Number: / Expiration Date: / //
Cardholder’s Name: / Amount:
Address:
City: / State: / Zip:
Telephone #: / () / AAA Account Number / 3231-3130

Please send this registration form with payment information, motor vehicle record and club approval letter to:

AAA National Office

MS 33

1000 AAA Drive

Heathrow, FL. 32746

Attn: Richard Chidester