Student Information Sheet

Please clearly print all information

Fill in and mail or email this form to address below

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DOWNLOAD Student Information Form

NAME(as printed on Learner's Permit)___________________________
ADDRESS_____________________________CITY_________ZIP______________
AGE_________BIRTHDATE____________________
SCHOOL_____________________________HOME/CELL#___________________

PARENT(S) NAME_____________________WORK/CELL#_______________

STUDENT DRIVER INFORMATION:
Which class are you registering for?_________________________
Learner Permit or Driver License#_____________________________
Hours of previous driving experience_________________________
Do you wear glasses and/or contacts?________________________
Do you have any handicaps?__________________________________
How did you hear about us? (Referral, internet, signs, school paper, other)
_________________________________________________________

Please mail or Call or e-mail cad74auto@Yahoo.com this information sheet to:
cad74auto@yahoo.com
2209 So. 138th Street 68144
Phone 402-719-8269com
Omaha, NE 68144
Bring payment of $450 check, cash or money order to the first class.

Questions? Call 402-719-8269