Community Behavioral Health Services, Inc. 
POSITIVE CHANGE IS POSSIBLE
Traffic Survival School (TSS) Registration

Enrollment Form

TSS class fee: $60

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 MVD correction letter or you will not be admitted. If you have misplaced your paperwork, contact the court or the MVD before the class.

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

CLASS DATES for 2010:

February 27
March 27
April 24
May 29
June 26
July 31
August 28
September 25
October 30
December 11

Who referred you to TSS? The Court or MVD?: *
Court or MVD Case Number: *
 
Student Name (First, Middle, Last): *
Date of Birth: *
Driver's License #: *
State that issued driver's License: *
P.O. Box or street address: *
City, State & Zip: *
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
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