1. REGISTRATION FORM
PLEASE COMPLETE THIS FORM AND RETURN WITH YOUR PAYMENT
NAME: DATE:
ADDRESS:
CITY: STATE: ZIP:
HOME PHONE: CELL PHONE:
EMAIL: SS#
DATE OF BIRTH: GENDER:
COMPANY/SPONSOR:
ADDRESS: PHONE:
CITY: STATE: ZIP:
COURSE SELECTION:
LIFE & HEALTH LIFE HEALTH
PROPERTY & CASUALTY
INSURANCE ADJUSTOR
BAIL BOND
*I UNDERSTAND THAT THE COURSES SELECTED ARE CONFIRMED WITH PAYMENT OF
TUTION & FEES. I ALSO, UNDERSTAND THAT MY NAME WILL APPEAR ON THE
PERMANENT CLASS ROLL ONLY AFTER PAYMENT HAS BEEN MADE. CASH, DEBIT OR
CREDIT CARD PAYMENTS ONLY!
STUDENT SIGNATURE: DATE:
Located in the:
Alpine Square
2969 Pelham Parkway, Suite P
Pelham, AL 35124