OMVIC Part-Time Student Registration form

Check this box if you require a French Manual.
Please fax your registration form to 1-705-722-1524
Part-Time Student Registration
Please provide, if applicable, your Georgian College student iden�fica�on number used at your
last registra�on. This will enable us to consolidate your student academic record.
Please provide your VALID OMVIC number if you are taking the course on a voluntary basis NOT at the request of OMVIC.
YOU MUST ENTER YOUR NAME EXACTLY AS IT APPEARS ON YOUR DRIVERS LICENCE
Last Name
Mr/Mrs/Ms/Miss
Given Name(s)
Apt./Unit
Home Address:
City or Town
Area Code
Province
Home Telephone
Postal Code
_
Email Address
_
OMVIC Automotive Certification Course
Date of Birth
Year
Month
Day
Please include your Drivers Licence Number:
Course Code:
OMVC 1000 Self Study: $260.00
Method of payment:
* Debit credit cards are NOT accepted
Visa
MasterCard
Amex
Name of Card Holder:
STATUS IN CANADA (Please check off one of the boxes listed below)
Credit Card #
CANADIAN CITIZEN
PERMANENT RESIDENT (LANDED IMMIGRANT)
Expiry Date:
Signature:
WORK PERMIT
Date:
NOTE: For COMPANY BILLING -
*
STUDY PERMIT
Authorized Signature & Title are required for processing
*
VISITOR PERMIT
FREEDOM OF INFORMATION AND PROTECTION OF PRIVACY ACT
The personal informa�on on this form is collected under the legal authority of the Colleges & Universi�es Act, R.S.O. 1990, Reg. 770. The informa�on is used for
the administra�ve and sta�s�cal purposes of the College and/or the ministries or agencies of the Government of Ontario and the Government of Canada.
Student informa�on and grades will be communicated to the Ontario Motor Vehicle Industry Council (OMVIC), and some informa�on will also be used by the
College solely for educa�onal follow-up and updates. For further information please contact The Automotive Business School of Canada, Room H130, Georgian
College, One Georgian Dr., Barrie, Ontario L4M 3X9. Phone (705) 722-1513, Toll Free: 1-877-722-1513.
Signature:
Date:
If you'd like for your package to be couriered to a dealership/business address, please also complete the following information:
Dealership/Business Name:
Dealership/Business Address:
City:
Telephone: (
Postal Code:
)
-
The tuition fee is subject to the refund policies of Georgian College
REFUND POLICY: Full refund, less $20, will be provided if written request is received in writing within 10 business days of registration.
2015\OMVIC\OMVIC Reg Form