Continuing Education Registration Page


STUDENT INFORMATION

First Name: Last Name:
Email Address: Date of Birth:
Home Address: City, State, Zip:
Home Phone #: Cell Phone #:
Insurance Lic #: License Exp Date:


EMPLOYER INFORMATION

Business Name: Contact Person:
Address: City, State, Zip:
Phone: Fax:


CLASS INFORMATION

Course Date: Choose Session: Choose Location:

(For multiple courses, please use the "Comments" section below to type in the dates of the addtional classes)


PAYMENT INFORMATION

Credit Card #: Exp Date:
CVV2 Code: Billing Address:
 
I would like to pre-pay for the 24-credit package (If Yes, Price Per Class Drops to $43.75)
Comments / Additional Classes:
Match Letters on Right: USA    (This step prevents SPAM being sent to us)
I have read and accept the terms described HERE.  Initial to Agree: 
 


Tuition Fees

1/2 Day (3 Credits): $60
Full Day (6 Credits): $100
Package (24 Credits): $350

 

Student Links

Check Your C.E. Credits
Enroll for the State Exam
Renew Your License
Contact the Dept. of Insurance
Forms & Documents

Corporate Information

Mailing Address
P.O. Box 579
Lakehurst, NJ 08733-9998
Phone: (732) 370 - 8111
Fax: (732) 370 - 8112

Atlantic School of Insurance

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