Driver Improvement Program (DIP) Enrollment Form
For enrollment for the DIP program hosted by the Rappahannock Area ASAP (RAASAP)
Email address *
What is your full name? *
Your answer
What is your mailing address? *
Your answer
What is the best phone number to reach you? *
Your answer
What is your Virginia Driver's License Number or Social Security Number? *
Your answer
What is your date of birth? *
MM
/
DD
/
YYYY
What date are you requesting to enroll for DIP? *
MM
/
DD
/
YYYY
Why do you need to take DIP? *
For Court Directed enrollees only: Which court ordered your enrollment?
Your answer
For Court Directed enrollees only: What was your offense/charge?
Your answer
For Court Directed enrollees only: What was your original court conviction date?
MM
/
DD
/
YYYY
For Court Directed enrollees only: When is your return to court date?
MM
/
DD
/
YYYY
Further information for participation types
* Please note that insurance premium reductions or safe driving points may not be awarded if the clinic was Court Directed

** Please note that insurance premium reductions cannot be given if the clinic was DMV Directed

*** Please note that attending DIP for insurance premium reductions, it is at the discretion of the insurance company to offer the reduction in premiums for attending this clinic. Safe driving points cannot be given if the clinic was attended for insurance purposes.
RAASAP Policy Acknowledgements
Seats for DIP are not guaranteed until registration and payment is received AND acknowledged by RAASAP staff. FEES ARE NON-REFUNDABLE. Late arrivals will not be allowed to attend. Missed sessions may be rescheduled for a future session as available. There will be a $25.00 rescheduling fee unless RAASAP is notified no later than close of business on the Thursday prior to class. The rescheduling fee must be paid prior to rescheduling.
By typing my name below, I acknowledge the RAASAP policies stated above. I also understand that I will be sent a copy of my enrollment form to provide an electronic signature: *
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Rappahannock Area ASAP. Report Abuse