High School Driver Education - The Key To Safer Drivers
Membership Application
Name: First _______________ Last _________________________
School/Organization _________________________ ISD # _____
Home Address __________________________________
City _____________ State ____ Zip Code _______
Work Address _____________________________ [ ] Retired
City _____________ State ____ Zip Code_______________
Send MDTSEA materials to [ ] Home or [ ] Work address.
Phone (H) (___) ___ ____ (W) (___) ___ ____ (C) (___) ___ ____
E-mail address ______________________________________
Are you currently getting MDTSEA emails? . . . . . . . . . . . . . . . . . . . . . . . . . . . . [Yes] [No]
Are you currently teaching DE? . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . [Yes] [No]
License type . . . . . . . . . . . . . . [Board of Teaching] [Dept. of Public Safety] [Both] [None]
Are you currently the signer for your school? . . . . . . . . . . . . . . . . . . . . . . . . . . . [Yes] [No]
Are you an American Driver & Traffic Safety Education Association member? [Yes] [No]
Which state legislative district do you live in? . . . . . . . . . . . . . . . . _____ Work in? _____
Which congressional district do you live in? . . . . . . . . . . . . . . . . . . _____ Work in? _____
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 [ ]
Dues = $40.00 Membership year is Jan. 1 - Dec. 31
38917 Timber Road
Avon, MN 56310 Phone: 320 746 2619
Number __________________________ Expire Date ___/___/___