HTML Preview Driving School Receipt page number 1.
LICENSE NUMBER: _____________
http://www.wbdriving.com
email: WBdrivingacademy@gmail.com
141 New Road Monmouth Jct., NJ 08852
732-821-4911 y 609-448-5014
Page 1 of 2
Student Enrollment and Instruction Agreement
Student First Name: __________________________________ Student Last Name: ___________________________________________
Address: _____________________________________________ City: __________________________________ Zip: _______________
Home Phone: ____________________________ Date of Birth: ____/____/____ Student SSN #: _______ - ______ - ________
Cell Phone: _________________________ Height: _________ Weight: __________ Eye Color: __________
Permit/License #: ________________________________________________
PARENT INFORMATION:
Parent First Name: __________________________________ Parent Last Name: ____________________________________________
Parent/Guardian License #: ________________________________________ Parent email: ___________________________________
Parent Cell Phone: ____________________________________________
TRAINING
Windsor-Brunswick Driving Academy will supply a dual controlled (gas & brake) vehicle, a licensed driving instructor, and insurance for the
lesson. Windsor-Brunswick Driving Academy will obtain a permit (additional fee $10) which is to be kept in the instructor’s possession during
instruction. Should the student have a valid permit or license, he/she must present it to the instructor at time of instruction. The instructor may
refuse to allow the student to drive if he/she shows signs of any impairment or actions which could pose a hazard to the student or instructor.
Windsor-Brunswick Driving Academy DOES NOT guarantee the issuance of a NJ Drivers License to the student.
The vehicle to be used for instruction has: __X__
automatic transmission; ____ standard transmission; and shall be equipped with, at
minimum, a brake for both the instructor and the student.
Type of Training Desired:
(check one)
_____ 6 hour behind-the-wheel instruction _____ Road Test _____ 2 hour refresher
PAYMENT
Amount due is to be paid in full prior to start of lessons. A $100 deposit is required upon signing of this contract and will be deducted
from the amount owed. 24 hour advance notice is required to reschedule any lesson and must be confirmed with a representative from
Windsor-Brunswick Driving Academy or student will be charged for that lesson. Appointments must be mutually agreed upon for date, time, and
location. This constitutes the entire agreement between the school and the student and no verbal statements or promises will be recognized.
The student may rescind this agreement within 72 hours of the first lesson and upon such rescission shall receive a refund for any lesson or
service not conducted or provided.
Please fill out, sign, and return this completed form along with the following documentation needed to process a
permit:
9 Check made payable to Windsor-Brunswick Driving Academy, LLC for $_______________
9 Check made payable to NJ MVC in the amount of $10.00 (permit fee)
9 The Motor Vehicle Commission Card signed by BOTH student and parent
9 The student’s Secondary School Driver Examination Card with test score (if applicable)
9 Original form of acceptable Identification
o Civil Birth Certificate (must have raised seal)
hospital birth certificates are not accepted
o Valid US Passport
o Current or Updated Resident Alien Card (green card)
o Citizenship papers
PHOTOCOPIES ARE NOT ACCEPTED! MUST PROVIDE ORIGINAL FORM OF IDENTIFICATION
Remember…Cancellations Require 24 Hour Advance Notification!
Receipt
Amount Paid: ___________ Payment Method:
(circle one)
Check# _______ Credit / Debit Cash
Signature: ___________________________________________ Date: ___________ Dates of Instruction: __________________
Windsor – Brunswick Driving Academy
Returned Checks Subject To a $50 Returned Check Fee