REGISTRATION FORM

Name:                                           Company:

Office Address:Phone #:

City:                                        State:                Zip:

Email Address:

Home Address:Phone #:

City:                                         State:                Zip:

Date of Birth:                            SS#:

Home State License #:

Type of License:


Location and Date of Class:
(Note - To select the location, scroll down to find the location you want and click on the box.)

Please let us know which states you are licensed in:
(Note - To select the states you are licensed in, hold down the control key, scroll to the states you need, and click the box.  If you do not find a state/providence listed, then we are not approved in that state/providence.)


Number of Licenses:






Type of Payment: 






(To ensure security, if you pay by credit card, fax info to
239-353-1419.  No corporate credit cards please.  If you choose to use a credit card, add 5% to the total for
processing fee.)

Please let us know if you have any additional comments or questions:





                  



                                                                                                          



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STAEHELI SEMINARS
Life and Health
Property Casualty
CFP
CLU
One License - $227
2 - 9 Licenses - $337
10 - 24 Licenses - $447
25 - 50 Licenses - $557
Check
Invoice
Visa
Master Card