Kansas City Chapter of the Society of CPCU � Education

Document Sample
Kansas City Chapter of the Society of CPCU � Education Powered By Docstoc
					                    Kansas City Chapter of the Society of CPCU
                    Class Registration Form



Check:
    Student
      Name                    ________________________________________________
      Company                 ________________________________________________
      Telephone #             ______________________
      Email Address           ________________________________________________

    Company
      Company Name            ________________________________________________
      Contact Name            ________________________________________________
      Contact Address         ________________________________________________
                        `     ________________________________________________
      Contact State/Zip______________________
      Contact Email           ________________________________________________
      Contact Telephone       ______________________

Registration Details
Student Name*                 Student Email*             Class   Date       Cost   Payment
                                                                                   Attached
                                                                                   Y/N




* - column may be left blank if “student” is selected, above

Please include credit card information below if paying by credit card:

Type____________________ (Visa, MC, American Express)

Number: _________________________________

Expiration Date: ______________


Send form to: Ron Hamilton, Educational Chair at ron_hamilton@swissre.com

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:3
posted:7/27/2012
language:
pages:1