Author: XP User

P.O. Box 3595 Lower Andy Roberts Street St. Johns Antigua
Tel: 268-773-6145

Mr. Mrs. Miss. Ms
First Name:……………………Middle Name………………….….Last Name:…………………
Date Of Birth:……/….../……… Sex: ……………………
Address:……………………………………………………………………….
………………………………………………………………………………...
Permit No:……………… Issued Date:……/………/… Expiry Date……./…../…..
Telephone Home:…268-…………………. Telephone Work:…………………..
Cell Phone:…268-………………………. E-mail:………………………………
Employer Name:………………………………………………………………………………
Employer Address:……………………………………………………………………………
Employer Telephone:…268-…………………………….
Do you have access to a motor vehicle? Yes No
Have you driven a motor vehicle before? Yes No
Type of motor vehicle prefer Manuel Automatic
Payment terms $50 EC per class
Payment terms $ FOR 5 Classes % off
Payment terms $ FOR 10 Classes % off
Payment terms $ FOR 15 Classes % off
Signature of Applicant……………………... Approved By:…………………...
Date:…………………. Date:……………………………..

ENROLMENT FORM

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