Application for Behind The Wheel Instruction

Our simple 2 step process is all you need to get started. Please fill out the information below, in its entirety. Once the form is completed, you will be directed to pay the application fee of $75.

Please check your spelling, and for best results, utilize your Keyboard’s TAB Key. As soon as your Application Form and payment are received, someone from Learn To Drive, LLC. will contact you to discuss scheduling your behind the wheel lessons.

 

Basic Info


Student's Full Name: (required)

Student is:

Yes, I am interested in taking the Driver's Test through the Learn To Drive PA 3rd party affiliate! (optional)

Student Referred By:

Request Instructor:
Sean HickeyKen AdelbergerPam CollinsBruce MonteiroRona DeGannesNo Preference

Found us by:
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Student SSN Last 4 Digits (State Required):

Student's Contact Info


Street Address:

Apt or Unit #:

City:

State:

Zip Code:

Mailing Address if Different (City and Zip Required):

Student's Cell (required)

Home Phone

Parent Name:

Parent's Cell

Student's Email (required)

Parent's Email (required)

School You Are Attending

Permit Information


The following questions require you to provide important dates and numbers. Please use this Date format: January 01, 2016, and Phone format: 123-456-7890.

Student's Date of Birth (Month Day, Year):

Student's Driver ID Number (Include Dashes, 8 digits only):

Test Eligibility Date:

Permit Expires:

Additional Comments


Applicant understands that by submitting this form, Applicant or Applicant's legal guardian or Parent indicates that he or she has read and agrees with all Terms and Conditions set forth on this Site and agrees with the statements made herein.

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Please Note: All application and processing fees are non-refundable, except at the sole discretion of Learn To Drive, LLC. An application and processing fee of $75.00 is required and can be submitted by mailing a check or money order if online payment cannot be processed.