GEORGE WEISS INSURANCE SCHOOL

REGISTRATION FORM

 

The following form is provided for you to print, fill out, and fax to our office. If you are registering for CE classes, please review the schedule and kindly note on the registration form which classes you are registering for.

A confirmation/reminder (with directions) will be faxed to you the week before the class. If you have any questions, please contact our office at: (732) 251-2900

You may mail the registration form with tuition payments to the address listed below, or you may fax registration forms with credit card tuition payments.

Phone # 732-251-2900 - Fax # 732-251-3890


Name: ________________________________________________________________

Address: _______________________________________________________________

Home Phone: (___)-_____-______ Cell Phone: (___)-____-_______

Fax Number: (___)-_____-_______

Business Phone: (_____)-_____-_______________

Employer/Sponsor: ____________________________

E-Mail address: ____________________________


Present Licenses you currently hold: (Please check)

LIFE __, HEALTH __, PROPERTY/CASUALTY__, FINRA __, CPA__, CFP__ RE__

 

Please register me for the following course:

____ LIFE INSURANCE COURSE ---------------------------- $310.00

____ HEALTH INSURANCE COURSE ------------------------ $310.00

____ LIFE & HEALTH INSURANCE COURSE -------------- $390.00

____ CASUALTY / PROPERTY ONLY COURSE -------------- $440.00

____ PROPERTY & CASUALTY INSURANCE COURSE ---- $650.00

____ LIFE/HEALTH AND PROPERTY/CASUALTY ---------- $795.00

 

____ 3 CE CREDITS at Old Bridge Location ------------------- $39.00

____ 6 CE CREDITS at Old Bridge Location ------------------- $69.00

 

____ 4 CE (CAIP & PAIP) at Old Bridge --------------------$60.00

____ 4 CE (LTCP Refresher / NFIP) at Old Bridge --------$50.00

____ 8 CE (LTCP Certification) at Old Bridge ------------ $95.00

 

____ 3 CE CREDITS at Outside Location -------------------- $75.00

____ 6 CE CREDITS at Outside Location ---------------------$95.00

 

____ 6 CREDITS - REAL ESTATE CE ---------------------- $95.00

____ 12 CREDITS - REAL ESTATE CE ---------------------$150.00

 

Course Title: ______________________________________

Class Date: ______________________________________

Class Location: ____________________________________

Student Signature: _________________________________

 

Payment Method:

____ Cash, _____ Money Order, ______ Check (#_______________________________)

Please Charge My: _____ AMEX, _____ VISA, ______ MASTERCARD

Total Tuition Amount: __________________

Credit Card Exp. Date: _________ / ___________

Credit Card #: _________________________________________________

Cardholder's Signature: ___________________________________________


Tuition is due prior to class and must accompany this form. Tuition includes all books and study materials.

No refunds after course assignments and/or schedules are arranged.

All courses include NJ CORE (State Law) & practice exams.

Please be advised that the school will confirm all class schedules and the book will be mailed to you upon receipt of registration form.

George Weiss Insurance School   1816 Englishtown Rd.   Old Bridge, NJ 08857  : (732) 251-2900   Fax (732) 251-3890
Copyright © 2016 George Weiss Insurance School. All rights reserved.