Segment 2 Registration An asterisk (*) indicates a required field. Last Name First Name Middle Name Your full mailing address for Secretary of State Records Birthdate Email (do not enter “AOL.com” Email, we will not receive your registration.) Please list 2 phone numbers in case one doesn’t work Which Class Location? Burton Carman-Ainsworth Flushing Swartz Creek Which Class date and time? Did you prepay for Segment 2 Yes No Level 1 issue date. (top line of numbers) Have you had your white Level 1 License at least 90 days? Yes No If possible, please send a picture of your Level 1 license How did you hear about us? Friend or someone you knew Online search Flint Journal ad Yellow Pages phone book Other information Spam Protection Enter this word: HTML Form Powered By Best Contact Form Pay for Teen Driver Education on Square Market .