Address________________________________

City____________________ Zip_____________

Return to:

Florida Insurance School
P.O. Box 3522
Tallahassee FL 32315

____Check Enclosed ( Company Checks Only )

Charge My: ____Visa____ MasterCard ____ Discover

Acct. #_________________________________

Amt.$______________ Exp. Date___________  Credit Card ID Code:  _______   Find Location?

Signature______________________________

Print Name_____________________________

Refunds will be issued as credit for future classes only.

***********************************************************
Office Use Only

Received__________________________________

Amt. $_______________Per. ________Co. ______

Company__________________________________

Fax #_______________________________

SS #________________________________

Check One

____ License Exam Prep Agent/Adjuster/Cust. Rep.

____ Life/Health & VA Qualification Courses *

____ Property & Casualty Qualification Courses

____ 40-hour P&C for CSR's

____ Surplus Lines Qualification Course

____ Surplus Lines Examination Preparation Course

____ Personal Lines Qualification Courses

Class #_________________

City________________________________

Textbooks must be ordered 5 working days in advance of class date.

* Life/Health Textbook needed for Life/Health & VA Qual. Course:
  In class - $40.00    _____
  Mailed - $45.00     _____