E-Mail Registration Form

1 (941) 363-7203

1. Fill out the student information below and Click Next.

* Don't Forget to fill out all of the Required Fields!

* Choose the course you wish to enroll in:

for INS003 Life Health and Variable Annuity 2.15 Pre-Licensing Only
for INS005, INS007, INS013 Only

* Name (Last, First, Middle Initial)
* Email or Fax #:

* 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 requirments.

*I declare under penalty of purjury 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 :

OnLine Training, Inc.