Please enter the requested information..

* Choose the course you wish to enroll in Pick a Course to enroll in! $200.00 -- 40hr 2-15 Life Health and Variable Annuities Pre-Licensing Course $40.00 -- Review for 2-15 Exam OnLine (Life and Health PassPrep Course) $475.00 -- 200hr 2-20 Property & Casualty OnLine Pre-Licensing Course $80.00 -- Review for 2-20 Exam OnLine (Property & Casualty PassPrep Course) $325.00 -- 40hr 4-40 Reg. Customer Svc. Rep. OnLine $85.00 -- CE Life 14hr OnLine $85.00 -- 14 hr OnLine Health CE $35.00 -- 3 hr OnLine Ethics CE $35.00 -- 3 hr OnLine Flood CE $35.00 -- 3 hr OnLine Ethics & the Client CE $35.00 -- 3 hr OnLine Health Savings Acct CE

* Enter the Course Reference number Please enter the complete reference number. (Example: RMI-8234-73305.) (CE) Life   D.O.I. #40321 Course Ref Date RMI-8234-(TBA) 09/21/08-12/11/08 (CE) Health     D.O.I. #40322 Course Ref Date RMI-8235-(TBA) 09/21/08-12/11/08 (CE) Ethics   D.O.I. #53604 Course Ref Date RMI-8279-(TBA) 09/21/08-12/11/08 (CE) Flood   D.O.I. #59082 Course Ref Date RMI-8276-(TBA) 09/21/08-12/11/08 (CE) Ethics & Client   D.O.I. #(TBA) Course Ref Date RMI-8277-(TBA) 09/21/08-12/11/08 (CE) Health Svg Acct   D.O.I. #(TBA) Course Ref Date RMI-8278-(TBA) 09/21/08-12/11/08 2-15 Life, Health and Annuities Pre-Licensing course # 37688--- Provider # 0443 Course Ref Date Day Time Campus Bldg.-Room#  RMI-8230-84690 08/23/08 Saturday 9AM-1PM Dale Mabry DHUM 207  RMI-8230-84721 09/06/08 Saturday 9AM-1PM Brandon BACA 107B  RMI-8230-84691 09/13/08 Saturday 9AM-1PM Dale Mabry DHUM 207  RMI-8230-84722 09/20/08 Saturday 9AM-1PM Brandon BACA 107B  RMI-8230-84692 10/04/08 Saturday 9AM-1PM Dale Mabry DHUM 207  RMI-8230-84723 10/11/08 Saturday 9AM-1PM Brandon BACA 107B  RMI-8230-84693 10/25/08 Saturday 9AM-1PM Dale Mabry DHUM 207  RMI-8230-84724 11/08/08 Saturday 9AM-1PM Brandon BACA 107B  RMI-8230-84694 11/15/08 Saturday 9AM-1PM Dale Mabry DHUM 207  RMI-8230-84725 12/06/08 Saturday 9AM-1PM Brandon BACA 107B   2-15 Life, Health and Annuities PassPrep Course Ref Date Time Bldg.-Room# RMI-8231-(TBA) 09/21/08-12/11/08 Online Online 2-20 General Lines Insurance Call Brandon Test Center (813) 253-7820 for appt for exam course # 41518 -- Provider # 0443 Course Ref Date Day Time Campus Bldg.-Room# RMI-8060-80322 08/15/08 Friday 9AM-1PM Brandon BACA 107B RMI-8060-84711 08/29/08 Friday 9AM-1PM Brandon BACA 107B RMI-8060-84712 09/26/08 Friday 9AM-1PM Brandon BACA 107B RMI-8060-84713 10/31/08 Friday 9AM-1PM Brandon BACA 107B RMI-8060-84714 11/21/08 Friday 9AM-1PM Brandon BACA 107B RMI-8060-84715 12/12/08 Friday 9AM-1PM Brandon BACA 107B 2-20 General Lines PassPrep Course Ref Date Time Bldg.-Room# RMI-8232-(TBA) 09/21/08-12/11/08 Online Online 4-40 Registered Customer Service Representative course # INS005 Course Ref# Final Exam Date Day Time Campus Bldg.-Room# RMI-8233-84689 09/13/08 Saturday 9AM-1PM Dale Mabry DHUM 212 RMI-8233-84719 10/11/08 Saturday 9AM-1PM Brandon BACA 107B RMI-8233-84689 11/15/08 Saturday 9AM-1PM Dale Mabry DHUM 212 RMI-8233-84720 12/06/08 Saturday 9AM-1PM Brandon BACA 107B

* Name (Last, First, Middle Initial)   * Email or Fax # *Retype your email address

* Home Phone *Work Phone

* Permanent Address Street City State Zip Code

*SSN# (123-45-6789) *Date of Birth (day / mo. / yr.) *Sex Male Female * The following information is requested by the U.S. Office of Education - Please Select One White, Non-Hispanic Asian or Pacific Islander American Indian or Alaskan Native Black, Non-Hispanic Hispanic * The following information is required for some courses - Please Select One I am a Highschool graduate. I am not a high school graduate. *Residency Statement I certify that I have resided in Florida as a permanent resident for the past twelve consecutive months or longer or otherwise meet the residency requirements outlined in the law of the State of Florida. I have not resided in Florida as a permanent resident for the past twelve consecutive months and I do not meet the residency requirements. *I declare under penalty of perjury punishable by law as a misdemeanor under Section 837.08, F. S., that the forgoing is true and accurate. I do. I don't.

2. Fill out the Credit Card information below and Click Next * Don't Forget to fill out all of the Required Fields!

* Name as it appears on the credit card (IF DIFFERENT FROM STUDENT NAME)

* Credit Card Billing Address (IF DIFFERENT FROM STUDENT ADDRESS) Street City State   Zip Code

* Credit Card type Visa  or Master Card

* Credit Card Number Exp. Date

* Card Holder's Email Address or Fax # (such as yourname@isp.com) * Card Holder's Phone (xxx-xxx-xxxx)

* I certify that I am the card holder or have the card holder's permission to make this purchase. I am the card holder I have permission

Questions or Comments: