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  Course Enquiry Form - ACT  
     
 
Required fields are those marked with (*)
MY LICENCE INFORMATION
Do you hold a current Australian car licence?
Yes No   *
(If yes, please enter licence details)
Licence Type:
Learner Provisional Open
Licence Number:
Issuing State:
   
MY CONTACT DETAILS
Full Name:
* (as shown on your Licence)
Preferred First Name:
Email:
*
Mailing Address:
*
Suburb:
*
State:
*
Postcode:
*
Mobile Ph No:
Alternate Number:
(between 9am and 5pm, Monday to Friday)
Date of Birth:
*
Gender:
Male Female *
 
COURSE INFORMATION
Course Type:
*
 
MY MOTORCYCLE / SCOOTER PREFERENCES
I wish to:
Hire Provide My Own *
Motorcycle Type:
Geared Motorcycle Automatic Scooter *
   
FEE PAYMENT
Payment in full is required at least 5 full working days before the course after which unpaid bookings will automatically lapse.
 
We will contact you shortly by telephone to agree course dates and times and confirm your booking.
 
 
     
 
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June 22, 2010
 
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