Enrollment Agreement (3B) Video

Broker B Application Video

    Class Information:

    Enter Begin Class Date: Confirm Begin Class Date:
    NOTE for BEGIN Class Date above: MUST CONTACT VIDEO COORDINATOR FOR OVERRIDE (choose Today Only) - 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 before 12/16/21 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: 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.