JRF Enterprises, Ltd., dba
Mid-America Driver Training
530 Sand Ridge Rd.
Bowling Green, Oh.  43402

 Adult Remedial Program 

Name__________________________________________________________________ClassDate____________________ 

Address________________________________________________________City__________________________________ 

State_________________________________Zip____________________Telephone #__________________________ 

Date of Birth_________________________SS#____________________________License #________________________

Reason for taking Adult Remedial Program : ______two point credit
______twelve point suspension
______ operating a motor vehicle
            under the age of with a
            prohibited level of alcohol
______court/employer ordered
           (no point credit)

Classroom instruction will be held at 530 Sand Ridge Rd., Bowling Green, Oh. 43402 unless otherwise
noted here:_________________________________________________________________ 

FULL COURSE COST WILL CONSIST OF EIGHT HOURS OF CLASSROOM INSTRUCTION.  FULL COST OF THE COURSE IS $100.00.  COURSE FEE IS NON-REFUNDABLE.  IF APPLICANT IS UNABLE TO ATTEND HIS/HER SCHEDULED CLASS, FEE WILL BE RETAINED FOR THE NEXT AVAILABLE COURSE DATE.   

IT IS AGAINST THE LAW AND POTENTIALLY UNSAFE TO DRIVE TO THIS CLASS IF YOU ARE NOT IN POSSESSION OF A VALID DRIVER’S LICENSE OR PERMIT. 

MID-AMERICA DRIVER TRAINING SHALL PROVIDE A LICENSED INSTRUCTOR FOR THE ADULT REMEDIAL PROGRAM.
DRIVER TRAINING SCHOOLS ARE LICENSED BY THE OHIO DEPARTMENT OF PUBLIC SAFETY, OHIO TRAFFIC SAFETY OFFICE, 1970 W. BROAD ST., PO BOX 182081, COLUMBUS, OHIO 43218-2018.

I HAVE READ AND UNDERSTAND THIS AGREEMENT: 

SIGNATURE OF APPLICANT_________________________________________________________________ 

SIGNATURE OF MID-AMERICA OFFICIAL______________________________________________________

I THE UNDERSIGNED INSTRUCTOR, CERTIFY THE APPLICANT HAS RECEIVED ALL CLASSROOM TRAINING MANDATED BY THE OHIO REVISED CODE 4501.21.04 AND 4507.40.  COURSE MEETS AND EXCEEDS THESE REQUIREMENTS.
INSTRUCTOR’S SIGNATURE___________________________________________________________________ 

COURSE FEE: $100.00
PAYMENT DATE___________________________________AMOUNT RECEIVED__________________________________