Off-Road Vehicle Instructor Registration Form
Transcription
Off-Road Vehicle Instructor Registration Form
Reset Department of Public Safety Licensing and Registration P. O. Box 6000 Fredericton, NB E3B 5H1 (506) 453-5307 78-9486 (9/03) Ministère de la Sécurité publique Licences et enregistrements Case postale 6000 Fredericton (Nouveau-Brunswick) E3B 5H1 (506) 453-5307 OFF-ROAD VEHICLE INSTRUCTOR REGISTRATION FORM 1. Please check applicable boxes: Language preference: English French Registration for: All-terrain vehicles Motorized snow vehicles Please complete all sections of the form and return to the address indicated above. 2. Personal information: Name: Mailing Address: _______________________________ ______________________________ (First Name) (Last Name) _________________________________________________________________ _________________________________________________________________ (City / Town) (Postal Code) Telephone & Fax Numbers: (_____) ______________________ (Business) (_____) ______________________ (Fax) (_____) ______________________ (Cell) (_____) ______________________ (Home) 3. Canada Safety Council Certification Number: _____________________________________ 4. Do you provide off-road vehicle training through a business / organization? Yes No If yes, please complete the following section: Business / Organization: Mailing Address: Telephone Number: (City / Town) (_____) ____________________ (Business) (Postal Code) Date: _____________________ Registrant’s signature: Top