HEALTH / CE registration form-2008

HEALTH / 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, 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:
Accident & Health and/or Continuing Education Fee: $135 (check one)	Tuition cost INCLUDES study materials - No matter which option is chosen below, the fee will be $135. The best value for your money is option #3; Health Prelicensing and Continuing Ed. credit.
1) Accident & Health Prelicensing ONLY	12 hours of A&H Prelicensing
2) Continuing Education credit ONLY	12 hours of A&H Prelic. that counts ONLY as 12 hours of CE credit
3) Both A&H Prelicensing & A&H CE credit	12 hours of A&H Prelicensing and 12 hours of A&H CE credit
Class Locations:	Check a location below:
Wisconsin Sites:	March 8th: Waukesha - PFS office (1733 Manhattan Dr. #F)
	Sept. 20th: Appleton - La Quinta Inn (3730 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: