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* DD MM YYYY Drivers Licence NumberYour Address Street Address City State / Province / Region ZIP / Postal Code Date of the Offence Date Format: 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)?: Date Format: 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 NumberHealth Care Card Expiry Date Format: 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.PhoneThis field is for validation purposes and should be left unchanged.