Life Registration Form (general public) - 2010
Questions marked by * are required.
1.
Legal Name: *
2.
Home Address (no P.O. boxes): *
3.
City: *
4.
State: *
5.
Zip Code: *
6.
Identification: *
-
WI Drivers License
WI Identification Card
Other
7.
Home Phone Number: *
8.
Date of Birth (MM/DD/YYYY format): *
9.
Social Security Number:
10.
Company Name: (or type in "independent") *
11.
Manager Name:
12.
Manager Fax #:
13.
Credit Card Type: *
MasterCard
Visa
14.
Credit Card Number: *
15.
CVV Verification Code: (found on the back of the card, directly following the card number - 3 digits) *
16.
Card Expiration Date (MM/YYYY format): *
17.
NOTICE: All refunds will incur a 6% processing fee: *
I understand
18.
Life Class Fees: *
-
$135.00 (includes study materials)
Audit - (no fee) I am RE-TAKING class and already own updated materials
Audit $20.00 - I am RE-TAKING class but need updated materials
19.
Class Locations: *
-
Appleton - La Quinta Inn (3730 W. College Ave.)
Brookfield - PFS office (19601 W. Bluemound Rd. #110)
Eau Claire - Holiday Inn (2703 Craig Rd.)
La Crosse - PFS office (201 5th Ave South)
Madison - PFS office (2800 Royal Ave.)
Wausau - PFS office (216 South 3rd Ave.)
20.
Date of Class: *
21.
E-mail Address (for verification purposes, only):