SOUTH CAROLINA  REGISTRATION  FORM

Notice: Online registrations are processed through a secure server at CyberSource. Your student information is entered on this screen. On the next screen you may review your order. Following that, you may enter your Credit Card information and complete the transaction (within the secure server). OnLine Training Institute 2669 Forest Hill Blvd., Suite207 West Palm Beach, FL 33406-5953 Voice: 561-283-0333 Fax: 561-357-4957 Please call 866-357-0841 for tech support or registration assistance. Registrar: register@oltraining.com Admin: admin@oltraining.com Click here for Instructions Click here for Policies Congratulations - You have chosen to register for an OLT Insurance Course. It will take just a few minutes to complete the registration process. PLEASE COMPLETE ALL INFORMATION! After we receive your registration and process the charge, we will send the login and password information for each course registered to the student e-mail address below. Please allow one business day for processing. Course Information: NOTE: Your CE Credits will be reported to the State of South Carolina. How did you hear about us? Please Select ____________________ E-Mail Post Card Reseller Returning Student Search Engine Telemarketer Word of Mouth Fax OLT Staff (Required) Select one or more courses by clicking in COURSE ID checkbox: (Required) PRICE COURSE ID COURSE TITLE $28.00 INSCE001 Continuing Education - Elements of Life Insurance - Intermediate (SCDOI # 107909) $28.00 INSCE002 Continuing Education - Elements of Health Insurance (SCDOI # 107911) Student Information: (all required) Student Name: E-mail Address: Telephone, with Area Code: We accept the following methods of payment:

If you prefer to register by mail or fax... Please print this screen and mail it to us at: OnLine Training 2669 Forest Hill Blvd. Ste. 207 West Palm Beach, Fl 33406 or fax it to 561-357-4957 Write your payment information below:

Modified December 15, 2009 by Melody Schiesl