Minor Driver License Recertification Course Registration Form

This course is approved for instruction in North Dakota pursuant of North Dakota Century Code 39-06-01.1 and North Dakota Administrative Code Article 38-07.

Please print this form and mail it with your non-refundable $100.00 fee (check or money order) to:
Center for Extended Learning ~ Minot State University ~ 500 University Ave W ~ Minot, ND 58707.

If you wish to pay enrollment fee by VISA, MasterCard, or Discover, please complete:
ACCT #: _____________________________ Exp. _____/_____ V Code: __________

Authorized Signature: ____________________________________________________

You have four (4) months from the registration date to complete this activity. All tests must be passed with an 80% pass rate. You will be given multiple opportunities to take the tests.

Registration Date: __________________

Last Name: __________________________ First Name: _________________ MI:___

Former Name, if applicable:______________________________

E-mail Address: _______________________________________

(Instructions for logging into the online course along with a login and
password will be sent to this e-mail address. Please ensure it is valid.)

Birth Date: ____/____/____ Social Security Number: _______-_____-________

Present Mailing Address: _____________________________________________

City: _________________________________ State: ________ Zip: _____________

Home Phone: ___________________________ Work Phone: ______________________

Parent/Guardian to Complete:

I certify that ______________________________ (name of student) is a minor
whose driver's license has been cancelled by the North Dakota Department
of Transportation.
__________________________________          _____________________________
Parent Signature                                                           Student Signature

CEL Office Use Only
Contract # ________________ Date of Completion/Drop:_______________

Instructor: Howard Theige