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 (Completely Online Including Final Exam) $40.00 -- Review for 2-15 Exam (Completely OnLine - Life and Health & Variable Annuity PassPrep Course) $475.00 -- 200hr 2-20 Property & Casualty OnLine Pre-Licensing (Completely Online - Including Final Exam) $350.00 -- 52hr 20-44 Personal Lines Pre-Licensing (Completely Online - Including Final Exam) $80.00 -- Review for 2-20 Exam (Completely OnLine - Property & Casualty PassPrep Course) $325.00 -- 40hr 4-40 Reg. Customer Svc. Rep. OnLine $85.00 -- 14hr CE Life (Completely Online) $85.00 -- 14hr CE Health (Completely Online) $35.00 -- 3hr CE Ethics (Completely Online) $35.00 -- 3hr CE Flood (Completely Online) $35.00 -- 3hr CE Ethics and the Client (Completely Online) $35.00 -- 3hr CE Health Savings (Completely Online)

* Enter the Course Reference number Please enter the complete reference number. (Example: RMI-8234-73305.) NOTE: If "TBA" is shown, use date.. (CE) Life   D.O.I. #40321 Course Ref Date RMI-8235-01828 Open Registration (CE) Health     D.O.I. #40322 Course Ref Date RMI-8234-01827 Open Reigstration (CE) Ethics   D.O.I. #53604 Course Ref Date RMI-8279-01823 Open Registration (CE) Flood   D.O.I. #59082 Course Ref Date RMI-8276-01824 Open Registration (CE) Ethics & Client   D.O.I. #(TBA) Course Ref Date RMI-8277-01825 Open Registration (CE) Health Svg Acct   D.O.I. #(TBA) Course Ref Date RMI-8278-01826 Open Registration 2-15 Life, Health and Annuities Pre-Licensing Completely Online Including Final Exam course # 70952--- Provider # 0443 Course Ref Date  RMI-8230-01889 Open Registration   2-15 Life, Health and Annuities PassPrep Course Ref Date Time RMI-8231-01829 Open Registration Completely Online 2-20 General Lines Insurance Completely Online Including Final Exam course # 70950--- Provider # 0443 Course Ref Date RMI-8060-01808 Open Registration 2-20 General Lines PassPrep Course Ref Date Time RMI-8232-01830 Open Registration Completely Online Personal Lines Agent Completely Online Including Final Exam course # 70953--- Provider # 0443 Course Ref Date RMI-8900-01810 Open Registration 4-40 Registered Customer Service Representative course # INS005 Course Ref# Final Exam Date Day Time Campus Bldg.-Room# RMI-8233-98221 2/27/10 Saturday 9AM-1PM Brandon (TBA) RMI-8233-98337 4/24/10 Saturday 9AM-1PM Dale Mabry (TBA)

* 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 High school 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: