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

Choose Location:
Choose Session:
Course Date: Use a comma ( , ) to Register for Multiple Dates


PAYMENT INFORMATION

Credit Card #:
Exp Date:
CVV2 Code:
Billing Address:
 
Pre-Pay for 24 Credits?
   (If Yes, You Save $130 as Opposed to paying per class individually)
 
Comments / Questions?

Type in "USA" Below:
   (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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