Driving Application
Jim Pendergrass Driving School, LLC
Phone Number: 417-459-3553
jimpendergrass22@yahoo.com

Facebook Link: https://www.facebook.com/jimpendergrassdrivingschoolllc/
Email address *
How did you hear about me? *
Students Name *
Your answer
Student Phone Number *
Your answer
Address *
Your answer
Parent/Guardian Phone Number *
Your answer
Parent Email Address *
Your answer
Are there any medical conditions we should be aware of? *
If yes please explain
Your answer
Drivers License/Permit Number: *
Your answer
Issuing State: *
Your answer
Expiration Date: *
Your answer
Has the student already taken the DMV road test and failed? *
If yes, how many times
My child has permission to ride in vehicle with the instructor alone? *
If your child cannot ride with the instructor alone, and/or with another student, who must accompany them during their lesson?
Your answer
Preferred Driving Times:
Morning
Afternoon
Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
How many driving hours? *
Required
Payment *
Required
I have read the following statement: Instruction in the car is a one-on -one activity unless your son or daughter prefers to be with another student driver. The student will be driving on the streets in Springfield and surrounding areas which may include picking up the student at school or at the students home, depending on the parent's preference. *
Required
Today's Date: *
MM
/
DD
/
YYYY
Parent/ Guardian Name - Signature *
Your answer
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