LIFE 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)
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: *Skip this section if you are with PFS and paid your initial $199 fee*
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:
Life Fees: (check one) Tuition cost INCLUDES study materials
Life - BAS (I am with Primerica Financial Services)
Life - $125.00 (I am with a company other than Primerica, or am Independent)
Audit - Free (I am RE-TAKING class and already have an updated textbook)
Audit - $18.00 (I am RE-TAKING class but need an updated book for $18.00)
Class Locations: Check a location below:
Wisconsin Sites: Appleton - La Quinta Inn (3730 W. College Ave.)
Brookfield - PFS office (19601 W. Bluemound Rd. #110)
Eau Claire - Holiday Inn (2703 Craig Rd.)
LaCrosse - PFS office (201 5th Ave. South)
Wausau - PFS office (216 South 3rd Ave.)
Date of Class: , &
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 "safe list".

Additional Comments, Questions or Requests:


© 2008