Off-Road Vehicle Instructor Registration Form

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Off-Road Vehicle Instructor Registration Form
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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:
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