(PLEASE PRINT)
Name of person attending clinic    ______________________________

Address    __________________________________________________

Telephone    __________________   Date of Birth    ________________

Driver's license number    _____________________________________

Reason attending:  (check only one)
_____    Court directed
_____    DMV directed
_____    Insurance volunteer
_____    Volunteer
 
 

Mail completed form to:

Southwest Virginia Community College
Office of Continuing Education
P.O. Box SVCC
Richlands, VA  24641

FAX 1.276.964.7393 or 1.276.964.7719