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3A. CERTIFIED version Driver Record. Acceptable for DDC Course

Please fill out the registration form completely. Asterisk (*) indicate required fields

*Driver License Number:
*Date of Birth (mm/dd/yyyy):
*Last Four Digits of Social Security #:
*DPS Audit Number:

*First Name:
*Last Name:
*Mailing Address:

*City:
*State:
*Zip Code:	-

I, the licensee, hereby certify that I grant access on this one occasion to my Driver License/ID Card record, inclusive of the personal information (name, address, driver identification number, etc. ), to DefensiveDriving.com.