Success Learning, Inc. :: Class Registration

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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:
Prelicensing Classes - Tupelo
Life & Health: $210 (Textbook Included)
January 7-9, 2021 • Tupelo February 11-13, 2021 • Tupelo March 18-20, 2021 • Tupelo April 15-17, 2021 • Tupelo May 13-15, 2021 • Tupelo June 17-19, 2021 • Tupelo		July 15-17, 2021 • Tupelo August 5-7, 2021 • Tupelo September 16-18, 2021 • Tupelo October 7-9, 2021 • Tupelo November 4-6, 2021 • Tupelo December 2-4, 2021 • Tupelo
Textbooks & Study Aids
Have Your Orders Shipped Directly To You Before Class: $12 (USPS Media Mail, 4-8 Day Service) Have Your Orders Shipped Directly To You Before Class: $18 (USPS Priority Mail, 2-3 Day Service) Have Your Orders Shipped Directly To You Before Class: $26 (USPS Overnight Service)
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.