Order Form

Basic Drivers Improvement VIDEO

To complete the process by filling out the information below:

First Name

M

Last Name

Address, City, State, Zip Code

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 when you get your video tape and answer sheet in the mail. You must answer the questions the same way on your answer sheet. This way it shows 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 both times.
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

Safer Dixie Driving Schools automobiles are equipped with dual control safety equipment.

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