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	Location: Show All Long Island Queens (Flushing Office)
	No Classroom Available

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	Student Information First Name:  * Emergency Phone:  * Middle Name: Emergency Name:  * Last Name:  *   Emergency Relationship:  * Address:  * Wear Glasses/Contacts: -- Select -- Yes No  * City:  * How Did You Hear About Us: -- Select -- Bing Craigslist Drivers Program Driving Car Facebook Google Instructor Referred LocalVox Referral Walk In Yahoo Yellow Page (YP) Yelp  * State and Zip: -- Select -- NY    * Gender: -- Select -- Male Female  * Date Of Birth: Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec   Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Year 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022  * High School: -- Select -- Bayside High School Benjamin N. Cardozo High School Cathedral Preparatory Seminary Central Queens Y East-West School of International Studies Flushing High School Flushing International High School Forest Hills High School Francis Lewis High School Full Gospel Christian School Garden School Herbert H Lehman High School High School for Arts and Business Holy Cross High School Jamaica High School John Bowne High School Kumon Math And Reading Center Martin Luther High School Monsignor McClancy Memorial High School Newtown High School Queens Academy Queens High School of Teaching, Liberal Arts and Sciences Queens High School-Sciences Richmond Hill High School Robert F Kennedy Community High School Saint Johns Preparatory School St Agnes Academic School St. Francis Preparatory School The Bronx High School of Science The Lowell School Thomas A. Edison Career and Technical Education High School Townsend Harris High School William Cullen Bryant High School Windsor School World Journalism Preparatory School Student Email: DL/Permit #:  * Home Phone: * DL/Permit Issued:  * Student Cell Phone: DL/Permit Expiration:  * Temp Visitor Status:   Groupon / Yelp / Living Social Voucher#:
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	Payment Information                        We Accept: Billing First Name: * Credit Card Type: -- Select -- American Express Discover Master Card Visa * Billing Last Name: * Card Number: * Billing Address: * Expiration: Month 01 02 03 04 05 06 07 08 09 10 11 12 Year 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 2044 2045 2046 2047 2048 2049 2050 2051 2052 2053 2054 2055 2056 2057 2058 2059 2060 2061 2062 2063 2064 2065 2066 2067 2068 2069 2070 2071 2072 2073 * Billing City: * Security Code (What is This?): * Billing State and Zip: -- Select -- NY * Payment Amount:
	24 Hours notice is required for all cancellations on all appointments.