16 Hour Class Registrati

Community Behavioral Health Services, Inc.

POSITIVE CHANGE IS POSSIBLE

16 Hour Class Registration

Enrollment Form

Level II DUI Education (16-Hour Class)

YOU CAN ENROLL: in person at 463 S. Lake Powell Blvd, over the phone at (928) 645-5113, or online with this form.

If enrolling online, this form must be completed and emailed to CBHS by 8am on the Friday before the class, in order to ensure that you are registered.

On the day of the class, you MUST bring your court order or you will not be admitted. If you have misplaced your paperwork, contact the court before the class.

Space is limited. Registrations accepted on a first-come first-served basis.

CLASS DATES for 2010:

March 20 & 21
May 15 & 16
July 17 & 18
September 18 & 19
November 20 & 21

Which Court Referred You: *
Court Case Number: *

Defendant Name (First, Middle, Last): *
Date of Birth: *
P.O. Box or street address: *
City, State & Zip: *
Phone Number: *
Did you have a screening done? If yes please list agency and phone number: *

Date of class you will attend (see list of dates above): *

Type of Credit/Debit Card (Visa or MasterCard): *
Exact name on card: *
Card Number: *
Expiration Date: *
Billing Zip Code: *
Need a receipt? Enter your mailing address here::

CONTACT US:
Primary Business Address
PO Box 790
463 S. Lake Powell Blvd.
Page, AZ. 86040

Phone: 928-645-5113
Fax: 928-645-3254
Toll Free: 866-260-5577

CRISIS: 928 645-8180