Register for Behind-The-Wheel Instruction

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This form/information may be submitted below or by phone/voice mail or mailed to the following address:

PO Box 3405

Zanesville, Ohio 43702-3405

(740) 892-2101

Student's Full Name (as it appears on record of birth):

Student's Street Address:

PO Box/Mailing Address (if different):

City, County, State Zip:

Email Address:

Parent's Name:

Home Phone:

Parent's Cell Number:

Student's Cell:

Availability to drive with us (for example: Monday any time, Tuesday after 6, etc.):

Approximate Number of Hours Student has Driven (0-50 hours):

Student's Date of Birth (MM/DD/YYYY):


High School:

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