GEORGE WEISS INSURANCE SCHOOL REGISTRATION FORM

The following form is provided for you to print, fill out, and fax to our office. If you are registering for CE classes, please review the schedule and kindly note on the registration form which classes you are registering for.

A confirmation/reminder (with directions) will be faxed to you the week before the class. If you have any questions, please contact our office at: (732) 251-2900

You may mail the registration form with tuition payments to the address listed below, or you may fax registration forms with credit card tuition payments.

Phone # 732-251-2900 - Fax # 732-251-3890

Name: ________________________________________________________________

Address: _______________________________________________________________

Home Phone: (___)-_____-______ Cell Phone: (___)-____-_______

Fax Number: (___)-_____-_______

Business Phone: (_____)-_____-_______________

Employer/Sponsor: ____________________________

Present Licenses you currently hold: (Please check)

LIFE ____, HEALTH ____,

PROPERTY/CASUALTY____, NASD ___.

Please register me for the following course:

____ LIFE INSURANCE COURSE -------------------------- $310.00

____ HEALTH INSURANCE COURSE ------------------ $310.00

____ LIFE & HEALTH INSURANCE COURSE --- $390.00

____ PROPERTY INSURANCE COURSE --------------------------------- $440.00

____ CASUALTY INSURANCE COURSE --------------------------------- $440.00

____ PROPERTY & CASUALTY INSURANCE COURSE ----- $650.00

____ LIFE/HEALTH AND PROPERTY/CASUALTY ----------- $795.00

____ 3 CE CREDITS at Old Bridge Location ----- $39.00

____ 3 CE CREDITS at Outside Location ---------- $69.00

____ 6 CE CREDITS at Outside Location -----------$89.00

Class Date: ________________________

Class Location: ____________________________________

Insurance License #: _______________________________________

Student Signature: ____________________________________________,

Date: ___________________

Payment Method:

____ Cash, _____ Money Order, ______ Check (#_______________________________)

Please Charge My: _____ AMEX, _____ VISA, ______ MASTERCARD, ______ DISCOVER

Total Tuition Amount: __________________

Credit Card Exp. Date: _________ / ___________

Credit Card #: _________________________________________________

Cardholder's Signature: ___________________________________________

Tuition is due prior to class and must accompany this form. Tuition includes all books and study materials.

No refunds after course assignments and/or schedules are arranged.

All courses include NJ CORE (State Law) & practice exams.

Please be advised that the school will confirm all class schedules and the book will be mailed to you upon receipt of registration form.