2024 Drive My Life - Central Otago REAP

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* 1. Your Name

First Name

Last Name

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* 2. Please enter any other names you have been know by for example maiden name

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* 3. Course Location

Alexandra

Cromwell

Māniatoto

Roxburgh

Tapanui

Wānaka

Hāwea

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* 4. Licence Required

Learners

Restricted

Full

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* 5. Your Address

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* 6. Your Phone Number

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* 7. Your Email

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* 8. Alternate contact if we can't get hold of you

Name

Email Address

Phone Number

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* 9. Your Gender

Female

Male

Other

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* 10. NSN Number (National Student Number)

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* 11. Your Qualifications

No formal qualifications

NCEA Level 2/3, 6th Form Certificate or equivalent

Tertiary Qualification

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* 12. Your Date of Birth

Date / Time

Date

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* 13. Your Ethnicity

NZ European

NZ Maori

Australian

Pacifica

Asian

Middle Eastern/Latin American/African

Other (please specify)

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* 14. Are you a NZ Citizen?

Yes

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* 15. Are you a NZ Resident?

Yes

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* 16. Are you a Migrant or Refugee to NZ?

Yes

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* 17. English is

not my first language.

my first language.

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* 18. Please attach a photo of your Drivers Licence if you are applying for your Restricted or Full Drivers Licence. File size limit is 16MB

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 19. I have uploaded a image of my Drivers Licence

Yes

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* 20. Please let us know who has referred you to this course. (Drivers Licence only)

Name

Email Address

Phone Number

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* 21. Would you like information about disability support?

Yes

Thank you for completing your enrolment form.
If you have any queries or concerns about this course please contact

The Manager
03 4486 115 or 0800 267 327