Student/Attendee Registration Form
Name (Legal first, middle and last name): *
Your answer
Alabama Residence Address; *
Full address including City, State and zipcode
Your answer
Mailing Address (If different from residence address):
Full address including City, State and zipcode
Your answer
Phone (Daytime # or Cell #) *
(including area code)
Your answer
Alternate Phone #: *
(including area code)
Your answer
Date of Birth: *
Your answer
Last four digits of your SS#: *
This will be your examination and certification password
Your answer
Personal Email Address: *
Your answer
Company Email Address:
Your answer
Pre-licensing Course Selection: *
Course Type: *
Instructor-led Class Date Selection:
(Please visit us at http://www.ceresourcesinc.com/property-and-casualty.html to view class schedules)
Your answer
Do you currently have an insurance license? *
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