NMLS 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.
Identification: *
-
WI Drivers License
WI Identification Card
Other
10.
Credit Card Type:
MasterCard
Visa
11.
Credit Card #:
12.
CVV Verification Code # (found on the back of the card, directly following the card number - 3 digits):
13.
Expiration Date (MM/YYYY format):
14.
NOTICE: All refunds incur a 6% processing fee
I understand
15.
Course Fee(s): *
-
$250 for 20 hour NMLS class & state CE credit
16.
Course Locations & Dates: *
-
Green Bay - June 26-27 (PFS office - 1066 Mather St.)
17.
E-mail Address (for verification purposes, only): *