Enrollment Agreement (Broker)

Class Information:

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: —Please choose an option—ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Code:

Cell Phone:
Home Phone:
Business Phone:
Fax Number:
Email Address: *
How did you hear about us? —Please choose an option—Internet/WebSocial MediaFormer StudentREALTOR®Wyatt SignWord of MouthNewspaperYellow PagesVoice MailOther

Payment Information:

Payment Choices explained:

TUITION options:

• Either FULL Amount (or) DEPOSIT will hold your seat in class; balance due by 3pm on the Thursday before class begins.

• Credit Card is required for all ONLINE submissions.

• Checks, Cash, and Money Orders accepted at the office or by mail.

TEXTBOOK options:

• Materials included in price

• To get a head start, you can request the book before class: (recommended)

• {option: Mail Book}

  We will mail book to the address provided on this form. (includes $10 for shipping fee.)
  -- OR --

• {option: Office Pickup}

  Come by the office to pick book up (no charge)

• *Take note: there is no book for the 3A class

• Book will be given at class, if {option: At Class} is selected

PAYMENT CHOICE : * *read* 'Payment Choices explained' above, then select one$700 - Both Classes (dont send Unit 3-B book prior to class)$710 - Both Class Tuitions + Send Unit 3-B Book$345 - Unit 3-A Class Only (there is no book for this class)$355 - Unit 3-B Class (dont send book prior to class)$365 - Unit 3-B Class + Send Unit 3-B book prior to class)$150 - Both Class Deposit (dont send Unit 3-B book prior to class)$205 - Both Class Deposit + Send Unit 3-B book prior to class)$195 - Both Class Deposit + I will pickup Unit 3-B book prior to class)$130 - 3-B Class Deposit + Send Unit 3-B Book$120 - 3-B Class Deposit + I will pickup book prior to class$75 - One Class Deposit only - (dont send book prior to class)

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 #2 of the Terms and Policies require me to give timely notice or forfeit $75 if I do not show.