Continuing Education registration form - 2008

Student's Personal Information: *All fields are required unless specified otherwise
Legal Name: First: MI:
Last:
Address: (No P.O. Boxes, please)
City:
State:
Zip:
Phone#: (Home phone number 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: (check one) 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 Information:
Credit Card Type: (check one)
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:
Continuing Education credits/fees: (check one) For 2009 credit hours:
1) I will be taking an entire day of CE $90 for a FULL DAY - 12 hour/credit class
2) I can only take individual sessions ($35 each) I will be taking individual 4-hour $35 sessions (SPECIFY BELOW)
Times, Topics & Instructors:

8:00am-11:50am / Instructor: S. Freeman

Topic: "The Ethical Practices of Unblending the Families"

12:35pm-4:25pm / Instructor: R. Mueller (May) & J. Guzek (Sept.)

Topic: "Non-Qualified/Qualified Annuities"

5:10pm-9:00pm / Instructor: K. Kuplic

Topic: "Fraud Awareness"

Class Locations: Wisconsin Sites: May 17th: Brookfield - Midway Hotel (1005 S. Moorland Rd.)
Sept. 27th: Appleton - Paper Valley (333 W. College Ave.)
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