School Bus Clinic Registration http://bit.ly/icsbc
Turn left at Traffic Light, follow yellow (green) line to get into parking lot, use door on first street side
Map from Interstate 89 Exit 21
Turn left at Traffic Light, follow yellow line to get into parking lot, use door on first street side
CERTIFICATION #
Instructor will fill this in
Your answer
PARTICIPANT'S NAME AS PRINTED ON DRIVER"S LICENSE
(Last name, First name, Middle) Last Name _________,_First Name _________,_Middle ________ _ PLEASE PRINT YOUR NAME AS IT is spelled ON YOUR DRIVER'S LICENSE
Your answer
Date of Birth
Month _______________ Day ___________ Year ________________
MM
/
DD
/
YYYY
Driver License
License Number, _____________________________________ State_____________
Your answer
Check one of the following: if new endorsement
New and Type (Renewals please skip to next question)
Type of school bus endorsement
Renewal and Type answer one of the following 3 questions
Renewal       CDL/Type I
Type of school bus endorsement
New or Renewal and Type
Renewal      Type II
Mailing Address:
Number and Street , or PO Box ___________________________________________________
Your answer
Town, State, Zip _____________________________________________________________
Your answer
Home Phone:
Your answer
Work Phone:
Your answer
Clinic Date
Email Address:
Your answer
Clinic Location
Swanton
Clinic Instructor
Irene Cook
Your Question or Comment
Your answer
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