FAX REGISTRATION FORM
P O Box 1740, Flowery Branch, GA 30542-0029
Fax: 770-965-5080     Tele: 770-967-4427

   STUDENT INFORMATION
   Student's Name:    First:     M/I:     Last:
   Address   Street:
                      City:    State:   ZIP:
   Social Security Number:           Birth Date:
   Student's Email Address:   
   Student's Company Name:
   Georgia Agents License Number (if licensed): 


   List up to 3 Phone Number(s) where Student can be contacted:

   Work:   Home:    :

CREDIT CARD INFORMATION
   Select Credit Card:           Discover Card      MasterCard      Visa
   Credit Card Number:                          Expiration Date:   
   Card Verification Code: How to find this code  
   Card Member Name (exactly as on Card):
   Credit Card Billing Address - Street:  ZIP:
NOTE:  Refer to the  SCHEDULE  for information on Course Date(s) & Location(s) which may change.
Tuition may be higher for classes held outside the Atlanta area.  
Price
Select
 Course Course Location Course Start Date
$325 Life & Health
$325 Property & Casualty
$395 Xactimate 27 Training
$325 Series 6&63 Prep
$175 Variable Products
$49 4-Hr Long Term Care CE
$89 8-Hr Long Term Care CE
$55 Pers Umb & Ethics CE
$  << Enter Total Price for All Courses Selected   NOTE:  By submitting your registration request you are recognizing and agreeing to our policy of  NO REFUNDS.  If you are unable to attend your requested class, you may attend a future class at no additional charge for up to six months from the originally scheduled class. 
SIGNATURE REQUIRED: __________________________________________________

 

 
                      
Sign & P
rint this form then FAX it to 770-965-5080 or Email to joyce@joycewildes.com

Last Updated 03/23/2011