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.


12 Hours

6 Hours

Self Study Continuing Education Courses
Advanced Estate Planning12L/H$69.95MS
Understanding Life Ins. Plans, Policies12L/H$62.95MS
Delivering Quality Service12L/H$67.95MS
Estate Planning Concepts25L/H$81.95MS
Life & Annuity Suitability Standards12L/H$62.95MS
Long Term Care12L/H$69.95MS, AL
Long Term Care Concepts12L/H$69.95MS
Life Insurance Policy Comparison & Underwriting12L/H$69.95MS
Commercial Auto Coverage12P/C Adj.$69.95MS
Commercial General Liability12P/C Adj.$69.95MS
Delivering Quality Service12P/C Adj.$67.95MS
Homeowner 200012P/C Adj.$69.95MS
Workers Compensation Coverage12P/C Adj.$69.95MS
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:

P.O. BOX 2221
TUPELO, MS 38803

Once payment has been received and processed, your order will ship promptly.