Enrollment Agreement (3B) 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

I understand 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.

Student Information:

Have you attended classes here before?* YesNo

Company Name:
First Name:*
Middle Name:
Last Name:*
Nickname: for class purposes
Social Security Number:*
Street Address:
City: State: ---ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Code:
Cell Phone:
Home Phone:
Business Phone:
Fax Number:
Email Address:*
How did you hear about us? ---Internet/WebSocial MediaFormer StudentREALTOR®Wyatt SignWord of MouthNewspaperYellow PagesVoice MailOther

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 : *--read--'Payment Choices explained' above, then select onePAYMENT OPTIONS: $372 - Full Payment + (option: Mail Book/Materials) $350 - Full Payment + (option: Office Pickup of Book/Materials)
CHARGE to Credit Card: *choose one:VISAMasterCard «« 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: *

Additional Notes to Office Manager (optional):

Acceptance of Terms and Policies:*

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

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