The Agent's Choice Insurance School
Insurance Pre-Licensing and Continuing Education
(336) 774-9400 (800) 941-4440

Continuing Education Online Course Registration Form

Course Descriptions


Last 5 Digits of SS#	NPN Get Your NPN
Birth Month

Name As it appears on your insurance license.	First Name: Middle Initial: Last Name: Jr./Sr./Etc...:
Name of Person Paying
Address
City
State
Zip Code
Home Phone
Work Phone
Cell Phone
Fax Number

Email	(Please provide an active email address.)
Password	(Please create your own password. Passwords can not contain # symbols.)
Confirm Password

Choose Credit Hours

Payment Method
Agency Affiliation


	Once payment has been made, you will be able to open your courses from our course library.

Comments

	Refund, Check, and No Show Policy There will be a $25.00 returned check charge on all checks returned. Any refunds will be subject to a 10% administrative fee deducted from the return. There will be no refunds on self-study courses - no refunds on books, computer programs, or other material purchased. All courses begin the time the self-study material is received. The student is responsible for the fees unless other arrangements have been made and approved by the school.
	Once you submit this form you will be directed to our payment options. If you wish to pay by credit card, you will be directed to our online course catalog. If you choose to pay by cashier's check, money order, or cash you will receive a link to our course catalog via email. All of our credit card payments are processed securely through
	Accept Refund Policy