Series 6/63 and Insurance CE registration form - 2008

Student's Personal Information: *All fields are required unless specified otherwise
Legal Name: First: MI:
Last:
Address: (No P.O. Boxes)
City:
State:
Zip:
Phone#: (Home # preferred) ( ) - extension:
Home: Work/Office: Mobile/Cellular:
Date of Birth: YEAR:
Social Security #: - - (123-45-6789 format)
WI Insurance License #: (8-digits; add zeros if necessary)
Identification: WI Driver's License: WI ID Card: Other:
Company Name: Independent:
(If you are NOT affiliated with a company check "Independent").
Manager Name:
Manager Fax #: (optional) ( ) -
Credit Card Info:
Credit Card Type: (check)
Credit Card #: - - - (1234-1234-1234-1234 format)
Expiration Date: (The DAY is NOT needed)
Verification Code #: Where do I find this?
*NOTICE!* (check box) All refunds will incur a 6% processing fee - I understand:
Series 6/63 and/or Life CE: $129 (check one)

*Kaplan materials will be used for instruction:

(Call #800-532-1039 to order materials for $42.)
Series 6/63 & CE credit 12 hours of 6/63 class that counts for Insurance CE credit
Life Insurance CE credit 12 hours of Insurance CE credit ONLY
Class Locations: Wisconsin Sites: April 19-20: Appleton - La Quinta Inn (3730 W. College Ave.)
October 4-5: Brookfield- PFS office (1733 Manhattan Dr. #F)
Verification: (optional) To verify we received your form, please enter your e-mail below:
E-mail Address:
Re-enter e-mail address:
Safe List Reminder: Add webmaster@insurancecramschool.com to your e-mail "safe list".

Additional Comments, Questions or Requests:


© 2008