State Advanced Class Registration Form - 2023 District/Driver InformationSchool District/Employer* Choose your PreService Instructor*Brandon AnnessJoe DietrichLori FangerRob HiggenbothamMichael HoffnerEvette MoodyMarvin PenningtonMike RedfernBilling Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Supervisor Name* Supervisor Cell Phone Number*Supervisor E-mail Address* Enter Email Confirm Email Location: Centerville*June 14 & 15, Plains Junior High School, Liberty Township, OH.June 21 & 22, Theodore Roosevelt HS, Kent, OHNumber of Drivers Attending*Please enter a number from 0 to 20.Driver 1*First NameLast NameThis class will be used for Recertification This class will be used for Recertification Driver 2*First NameLast NameThis class will be used for Recertification This class will be used for Recertification Driver 3*First NameLast NameThis class will be used for Recertification This class will be used for Recertification Driver 4*First NameLast NameThis class will be used for Recertification This class will be used for Recertification Driver 5*First NameLast NameThis class will be used for Recertification This class will be used for Recertification Driver 6First NameLast NameThis class will be used for Recertification This class will be used for Recertification Driver 7First NameLast NameThis class will be used for Recertification This class will be used for Recertification Driver 8First NameLast NameThis class will be used for Recertification This class will be used for Recertification Driver 9First NameLast NameThis class will be used for Recertification This class will be used for Recertification Driver 10First NameLast NameThis class will be used for Recertification This class will be used for Recertification Driver 11First NameLast NameThis class will be used for Recertification This class will be used for Recertification Driver 12First NameLast NameThis class will be used for Recertification This class will be used for Recertification Driver 13First NameLast NameThis class will be used for Recertification This class will be used for Recertification Driver 14First NameLast NameThis class will be used for Recertification This class will be used for Recertification Driver 15First NameLast NameThis class will be used for Recertification This class will be used for Recertification Driver 16First NameLast NameThis class will be used for Recertification This class will be used for Recertification Driver 17First NameLast NameThis class will be used for Recertification This class will be used for Recertification Driver 18First NameLast NameThis class will be used for Recertification This class will be used for Recertification Driver 19First NameLast NameThis class will be used for Recertification This class will be used for Recertification Driver 20First NameLast NameThis class will be used for Recertification This class will be used for Recertification Cost CalculationP.O. # (Note: no cash or personal checks accepted)* Treasurer E-mail Address* Enter Email Confirm Email Total Cost - $90 eachQuestions? Comments?Leave us your questions and/or comments and we will get back with you.Section Break