Student Registration Form

First Name* (exactly as in your driving licence)
Last Name* (exactly as in your driving licence)
Middle Name* (type N/A if you have none)

Date of Birth*

MaleFemale

"How did you find us?*"
Previous CustomerFriendsGoogle SearchSocial Media (facebook...)Others

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Home Address*
City*
Postal Code*

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Your Email*
Telephone Number*
Cell Number (required for pick-up contact)*

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Driver's Licence Number* (Driver's License number at the top of the card)
Licence Class/Conditions*

Licence Issued Date*

Licence Expire Date*

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Select the Course Enrolled* —Please choose an option—Basic Course: 10 Hour in-vehicle +15 Hour TheoryExtra Course: 14 Hour in-vehicle +15 Hour TheoryDouble Course: 20 Hour in-vehicle +15 Hour TheoryClass 5 Non-GDL Course: 6 Hour in-vehicle +15 Hour Theory10 Hrs. in-car lessons: 10 Hrs In-car Driving OnlyBrush-up Lesson: 2 Hour in-car Driving lessonsOnline Novice Classroom Training/ In-class Training: 15 Hours Theory CourseCar Rental for Basic Road TestOTHER

Payment Method
Paypal/Credit CardInterac e-transferCashCheque
Paid by - Name/email*

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Parents/Guardian's consent is given for student Under 18 years oldStudent is 18 years or older

Parents/Guardian's Name (required for student under 18 years old)
Parents/Guardian's Telephone (required for student under 18 years old)

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Other information (if any, max:140 characters)

I accept terms and conditions of Moxie Driving Academy.

Course Registration Date*