E-Mail Registration Form

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Registering for an OnLine Course is as easy as 1, 2, 3...

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:  
* 2.15 2.20, and 4.40 Pre-Licensing 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 :

 

Updated Dec. 20, 2004
by Joan Villari

OnLine Training, Inc.