Enrollment Agreement (3B) Video

Broker B Application Video

    Class Information:

    Enter Begin Class Date:
    Confirm Begin Class Date:

    NOTE for BEGIN Class Date above: (choose Today or date within next 4 days) - month and year are already entered;
    type the DAY only OR choose a date from dropdown box

    that my access to the Video Course will not be available until I receive my materials and that I must complete all course requirements including final exam within 21 days from the 'Begin Class Date' chosen above.


    * indicates REQUIRED fields below

    Student Information:

    Have you attended classes here before?* YesNo






    Social Security Number:*








    Payment Information:

    Payment Choices explained:

    TUITION options:

    • FULL Amount must be paid to begin VIDEO class.
    • Credit Card is required for all ONLINE submissions.
    • Checks, Cash, and Money Orders accepted at the office or by mail.

    TEXTBOOK options:

    • Book and materials are included in price of class and are not returnable.
      • {option: Mail Book/Materials} We will mail book and materials to the address provided on this form.
        (includes $22 for shipping fee.)
      • {option: Office Pickup} Come by the office to pick up book and materials (no charge)

    PAYMENT CHOICE : *
    CHARGE to Credit Card: * «« VISA or MasterCard ONLY
    Card #: *
    3-digit security code: *
    Expiration Date (MM/YY): *

    Name on Card: *
    Billing Address Number (used to process credit card): * (numbers ONLY)
    Billing Zip Code: *


    Acceptance of Terms and Policies:*

    (check both boxes below to accept, after reading the Terms and Policies)

    , I understand the Terms and Policies as part of this agreement. I am keeping a copy for my records.
    , I understand #3 of the Terms and Policies that no refund is due once the course materials are mailed or given to me.