- * Choose
the course you wish to enroll in:
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To schedule a final exam date
for the Accredited
Claims Adjuster (INS013), or Registered
Customer Service Rep (INS005),
please call Pamela Haskin at
(941) 363-7203.
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- * Name (Last, First, Middle
Initial)
- * Email
or Fax #:
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- * Home
Phone :
- *Work Phone:
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* Permanent Address:
- Street :
- City:
- State:
Zip Code:
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- *SSN# (123-45-6789):
* Date of Birth (ex: Jan. 10, 1980):
- *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:
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I am a High school graduate.
I am not a High school graduate.
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*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.
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