Fillable Utah Dot Pilo Escort Driver Re Certification (Page 2 of 2) in pdf

Utah Dot Pilo Escort Driver Re Certification Page 2

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Utah DOT Pilot/Escort Driver Re-Certification

Training provided by:

Select which option you would like to complete for the re-certification.

Online Course

DVD Course w/written test

Please send me just the course indicated (Fee of $115.75)

Please send me the course indicated as well as the Pilot/Escort Training Manual (Fee of 135.35)

Payment Information

Today’s Date: _____/_____/ ________

Study materials will not be supplied unless form of

payment is provided or indicated with credit card

Name:____________________________________

(First Name)

(M.I.)

(Last Name)

information. Personal checks are NOT accepted.

Company Checks or Money Orders will be

accepted.

X_______________________________________

**Sign Here**

Check Information:

Certification Number:________________________

Company Check

Money Order

Expiration date of certification:_____/ _____/ ____

Name on check:____________________________

Driver’s License Number:____________________

Check Number:_____________________________

State issuing license:_________________________

New photo (check one)

Yes

Credit Card Information

Physical Mailing Address:

Visa

AmEx

Discover

_________________________________________

Card Number: ______________________________

_________________________________________

Expiration: _____/_____ CVV2:_______________

(City)

(State)

(Zip Code)

Name on card: _____________________________

Email Address: ____________________________

(Required for internet run program)

Billing Address:____________________________

Home Telephone Number (____)______-_______

City, State, Zip:_____________________________

(____)______-_______

Work Telephone Number (____)______-_______

Phone Number of cardholder:

Any dishonored checks or credit card charges that cannot be processed for the full assessed course fees shall be subject to a minimum collection fee of $34.00

and/or reasonable attorney/collection agency/court costs/fees. Any certification provided will be null and void until such time as all fees/costs have been paid to

RSA Network Inc. in full.

OFFICE SPACE ONLY

: _________________

: ____________________

Valid

MVR

Username

Password

: ___________

: ______/______/______ Card Mailed:_____/_____/_____

Test

Recertification Package Sent