Minnesota Driver and Traffic Safety Education Association
MDTSEA     On Line Membership Form    
* denote required answers.
Register For a paper form to mail click here.
What is your first name? *
What is your last name? *
What nickname do you use?
What title do you use? (ie. Doctor)
What is your address? *
What city, state and zip code? *
What is your e-mail address? *
What school or organization? *
What school district number?
What home phone number? *
What work phone number?
What cell phone number?
Are you teaching driver education? Yes No
Are you the school signer? Yes No
Who are you licensed by? PLSB/Board of Teaching Department of Public Safety
          Both BoT and DPS No DE License
What is your Legislative district?
What Congressional district?
Regional workshops are held in the following towns. Which is closest?
Stillwater Marshall     Mankato     St. Cloud     Thief River Falls
Kasson (Rochester)     Willmar     Perham    Duluth    Shakopee
Are you registering for the Winter Workshop? Fee=$0 Yes     No    
Are you registering for the Conference?
No     Friday and Saturday $130
Friday only $110
Saturday only $90
Dues amount. 2023 dues = $40.00
I am a student at SCSU Dues = $ 0.00
How do you want to pay? I will mail a check to
    38917 Timber Road
    Avon, MN 56310.
Please use the card below for payment.
Comment or Question:

Are there any conference meals you will be skipping?
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debit card enter the information.
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What is your card number?
What is the security code?
What is the expiration date?
What is the card's zip code?
What is the amount being paid?
Minnesota Driver and Traffic Safety Education Association
Last Revision: January 2023
Copyright © 2021
Created: February 2021
E-Mail to MDTSEA Webmaster
Secretary Janice Jensen-Skoviera
601 Richland Ave SW
Willmar MN 56201
Phone 320 231 0489
URL: http://www.mdtsea.net/memberform.html