Contact - Registration Form for DriveSafe
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Full Name
Address as on License
City & Province
Postal Code
Email Address
Fax Number
Telephone
Cell number
How did you hear about us
Driver's License
Province & Expiry Date
License Class
Course Name
Date & Time
Location
Sponsor/Company
Payment Details
_______(Unit Price)
x
________
 (# of
Students)
=
________
Sub Total
Kwictech Interactive Inc. GST #89611 7447 RT @ 6%
________
Plus GST
Multiple Students: Please submit one form per student.
________
Total
Note: Cash is required at the start of the course if prepayment has not been possible.              
  

Method of Payment

  
Mail
Company Cheque
or Personal Cheque
Kwictech Interactive Inc.
The 100 Aker Wood, Box 160
Almonte, ON    K0A 1A0
Fax Registration Form to
613.256.6262
      
 Please make all cheque's payable to          Kwictech Interactive Inc.
AMEX, VISA, MasterCard
Credit Card Payment
 PLEASE DO NOT SEND CREDIT CARD DETAILS
One of our representatives will contact you to get personal details.
Please sign here to authorize credit card payment      _____________________.