Order Form

Birthday

MM/DD/YR

Driver's License Number

Phone

Ticket / Citation Number

County

Your Email Address

The following questions are for security purposes only. You will see these
questions again as you take the course. They will pop up randomly as you
go through the material. You will have 30 seconds to answer the question
correctly, or you will be blocked form continuing the course until you call
us and get a reinstatement code. This is how we insure the same person
that signed up for the course is taking the course. The information isn't
retained or used for any other reason. In fact, we don't care if you answer
truthfully, as long as you answer the same way each time.

Do you have any children?

Yes No

Did you get your ticket from a motorcycle officer?

Yes No

Are you married?

Yes No

Do you own a house?

Yes No

Are you a registered voter?

Yes No

Are you afraid of heights?

Yes No

Have you ever been to Europe?

Yes No

Do you drink coffee?

Yes No

Have you ever been to Hawaii?

Yes No

Do you wear your seatbelt while driving?

Yes No