Please fill in this form as completely as possible. Fields marked * are required
This form is secure and SSL encrypted, and all information is transmitted in an encrypted form.
If you prefer to open this form in a new window, in order to view or verify security information, please click here.
|
| Registrant Information |
| Name: * |
|
Social Security Number: * |
|
|
| Street Address: * |
|
City: * |
|
|
| State: * |
|
Zip: * |
|
|
| Home Phone: * |
|
Cell Phone: |
|
|
| E-Mail Address: * |
|
Birth Date (Month/Day/Year): * |
|
|
| Recruiter / Manager (if
applicable) |
| Recruiter / Manager Company: |
|
Recruiter / Manager's Name: |
|
|
| Street Address: |
|
City: |
|
|
| State: |
|
Zip: |
|
|
| Recruiter / Manager's Phone: |
|
|
|
| Sponsoring Insurance Company: |
|
|
|
| Continuing Education Seminars |
| Tuition: $96 (12 Hrs) or $69 (6 Hrs). Lunch included for 12 hrs. |
|
TBA |
12 Hours
6 Hours |
|
| Self Study Continuing Education Courses |
|
| Advanced Estate Planning | 12 | L/H | $69.95 | MS |
| Understanding Life Ins. Plans, Policies | 12 | L/H | $62.95 | MS |
| Delivering Quality Service | 12 | L/H | $67.95 | MS |
| Estate Planning Concepts | 25 | L/H | $81.95 | MS |
| Ethics | 4 | L/H | $69.95 | MS |
| Life & Annuity Suitability Standards | 12 | L/H | $62.95 | MS |
| Long Term Care | 12 | L/H | $69.95 | MS, AL |
| Long Term Care Concepts | 12 | L/H | $69.95 | MS |
| Life Insurance Policy Comparison & Underwriting | 12 | L/H | $69.95 | MS |
| Commercial Auto Coverage | 12 | P/C Adj. | $69.95 | MS |
| Commercial General Liability | 12 | P/C Adj. | $69.95 | MS |
| Delivering Quality Service | 12 | P/C Adj. | $67.95 | MS |
| Homeowner 2000 | 12 | P/C Adj. | $69.95 | MS |
| Workers Compensation Coverage | 12 | P/C Adj. | $69.95 | MS |
Normal shipping will be by UPS or Airborne Ground.
Shipping fees will be charged at the rate of $12 for the first course,
$3 for each additional course in the same package.
(USPS Media Mail Rates: 4-8 Day Service)
|
| How many courses are you ordering? |
|
Total Courses Cost: |
|
|
| Shipping Charges: |
|
|
|
| Payment Information |
| Method of Payment: * |
|
|
|
| Credit Card Number: |
|
Expiration Date: |
|
|
3 Digit Verification Code on Back of Card
(Visa Only): |
|
I authorize Success Learning to charge my
credit card. |
If sending payment as check or money order, please submit payment to:
SUCCESS LEARNING, INC.
P.O. BOX 2221
TUPELO, MS 38803
Once payment has been received and processed, your order will ship promptly.
|
|
|