Minnesota Driver and Traffic Safety Education Association

On Line Membership Form     * denote required answers.
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 Mantorville (SE Region)     Willmar     Perham    Duluth    Lakeville
Are you registering for the Winter Workshop? Fee=$25.00 Yes     No
Are you registering for the Conference?	No     Friday and Saturday $130 Friday only $110 Saturday only $90
Dues amount.	2024 dues = $40.00 I am a student at SCSU Dues = $ 0.00
How do you want to pay?	I will mail a check to     MDTSEA     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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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: December 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