Please Note: Payment only necessary for Part One (Cost covers both parts of the program)Your Surname* Given Names* Email* Contact Phone* Date of Birth* Day Month Year Drivers Licence Number Your Address Street Address City State / Province / Region ZIP / Postal Code Date of the Offence DD slash MM slash YYYY 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)?: DD slash MM slash YYYY Is there anything else we should know about?Payment Options $300 + $67 Vic Roads Fee (Without a Health Care card) $300 + $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.Health Care Card Number Health Care Card Expiry DD slash MM slash YYYY Non-refundable $100 deposit required.Please contact us to organise a $100 deposit. Deposit must be paid minimum 5 days prior to commencing the program. If deposit is not paid, you are not booked in. For advance payments, your payment must be made minimum 2 days prior to the program date.CommentsThis field is for validation purposes and should be left unchanged.