Continuing Education Registration Form - 2010
Questions marked by * are required.
1.
Legal Name: *
2.
Home Address (no P.O. boxes): *
3.
City: *
4.
State: *
5.
Zip Code: *
6.
Home Phone #: *
7.
Date of Birth (MM/DD/YYYY format): *
8.
Social Security #:
9.
MN/WI Insurance License #: *
10.
Identification: *
-
WI Drivers License
WI Identification Card
Other
11.
Company Name: *
-
Primerica Financial Services (PFS)
Other
12.
Manager Name: *
13.
Manager Fax #:
14.
Credit Card Type:
MasterCard
Visa
15.
Credit Card #:
16.
CVV Verification Code # (found on the back of the card, directly following the card # - 3 digits):
17.
Expiration Date (MM/YYYY format):
18.
NOTICE: All refunds incur a 6% processing fee
I understand
19.
Continuing Education Fee(s): *
-
$110 for full course - 16 hour/credit 2 day class
$35 for individual sessions - 4 hours each (see question #20 for choices)
20.
Individual Session(s) Selection:
October 2nd: Long Term Care (8:00AM-11:50AM)
October 2nd: Roth vs. Traditional IRA (12:50PM-4:50PM)
October 3rd: Ethics Part 1 (8:00AM-11:50AM)
October 3rd: Fraud Awareness (12:50PM-4:50PM)
21.
Course Location & Date: *
-
Hudson, WI (Hudson House- 1616 Cresview Dr.) - October 2 & 3, 2010
22.
E-mail address (for verification purposes, only): *