Registration Form

CE Seminar for Friday February 17th & 18th  

The Agent’s Choice School

Conference Room

3410 Healy Drive

Winston-Salem, NC  27103

 

Pre-Paid Tuition by 2/17/2012

 

Last 5 digits of SS #:  _________________ NPN:  __________________________

 

Name:  _____________________________________________________________

 

Address:  ___________________________________________________________

 

City/State:     _________________________________________________________

 

Zip Code: ___________________________________________________________

 

Home Phone:  _______________________________________________________

 

Work Phone:   _______________________________________________________

 

Cell Phone:     _______________________________________________________

 

Fax Number:  _______________________________________________________

 

E-Mail:  ____________________________________________________________

 

Agency Affiliation:  ___________________________________________________

 

Courses you are registering for:________________________________________

 

Registration Forms may be mailed to:

 The Agent’s Choice School

3410 Healy Drive, Suite 107

Winston-Salem, NC  27103

 

Seats are reserved upon payment.  Prices are turn-key!  CE credit hour fees included.