Life Registration Form - 2012
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: *
-
Primerica Financial Services (PFS)
Other
11.
Manager Name: *
12.
Manager Fax #:
13.
Credit Card Type: (Skip if you are with PFS and have already paid your initial $199 fee)
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: *
-
Life (BAS) - I am with Primerica Financial Services (PFS)
Life $135 - I am affiliated with a company other than Primerica, or am Independent
Audit - I am RE-TAKING class and already own updated materials
Audit $20 - I am RE-TAKING class but need updated materials
19.
Class Locations: *
-
Appleton - La Quinta Inn (3730 W. College Ave.)
Brookfield - Midway Best Western (1005 South Moorland Rd.)
Madison - PFS office (2800 Royal Ave.)
20.
Date of Class: *
21.
E-mail Address (for verification purposes, only):