Please Note: Payment only necessary for Part One (Cost covers both parts of the course)Your Surname*Given Names*Email* Contact Phone*Date of Birth* DD MM YYYY Drivers Licence NumberYour Address Street Address City State / Province / Region ZIP / Postal Code Date of the Offence What was your BAC reading?*Please provide a description of any other charges made:*Number of related offences in the last 10 years*Date of prior offence (if applicable)?: Is there anything else we should know about?Payment Options$250 (If offence was before 30/04/18)$250 + $67 Vic Roads Fee (Without a Health Care card)$250 + $34 Vic Roads Fee (With a Health Care card)For credit card payments please contact uson 9654 3321. Please note, the $67 and $34 fees are VicRoads fees and not ours and are required to be paid prior to commencement of the program. VicRoads fees are only for offences on 30/04 or after 30/04/18Health Care Card Number$50 deposit required.Please contact us to organise a $50 deposit. For advance payments, your payment must be made minimum 2 days prior to the course date.CommentsThis field is for validation purposes and should be left unchanged.