Personal Information:

Student Name:                              (Enter as First, MI, Last as it appears on your Driver License or State Identification Card)

Home Address:

City:   State:   Zip Code:

Social Security Number:             (Enter as xxx-xx-xxxx)  

Date of Birth:                              (Enter as mo-day-year)

Email Address:

Home Phone:                               Enter as 10 digits (xxx-xxx-xxxx)

Work Phone:  Enter as 10 digits (xxx-xxx-xxxx)

Other Phone:  Enter as 10 digits (xxx-xxx-xxxx)

Fax Phone:  Enter as 10 digits (xxx-xxx-xxxx)

Employer Information:

Employer Name, if applicable:

Manager Name: 

Work Address, if applicable:

City:   State:   Zip Code:

Home Study Course Information:

Type of course:   Life, Accident & Health - $129.99 Property & Casualty - $199.99

Home Study Payment Information:

Will you require an invoice for yourself or your Employer: No Yes - My Employer Yes - Myself

Will you require a receipt once your fee is paid: No Yes

Comments:

We do accept:  Visa, Mastercard, Discover, and American Express.

We also accept: Check, Money Order and Cash, made payable to:
Ruslander and Associates, 2312 Marbury Road, Pittsburgh, PA  15221

Please indicate your method of payment:

Visa Mastercard Discover American Express Check Money Order Cash

**If paying by check, please note that your check must be received in our office at least 5 business days prior to your materials being shipped or picked up for the course.  If you wish to pay by check, you will not be issued your completion certificate until your check funds have been processed and cleared by our bank.  Thank you.

**If paying by credit card, please provide the following:

Credit Card Number:       Expiration Date:    (enter as mo/yr)

Street Address Number as it appears on your credit card statement:      Zip Code where you receive your credit card statement: 

I would like to Pick-up my materials for Free Ship Materials for $14.99 .

I understand that there is a mandatory $15.00 registration fee for either class in addition to payment, and I agree to the charge:  Select One Yes, I accept the fee No, I do not accept the fee

PLEASE NOTE:  When you receive your credit card statement, the charges will appear as our subsidiary company "Here's The Pitch, Inc."

* In order to process your registration, we require that you review the terms of our cancellation policy.
 Click here to review the policy prior to continuing your registration.

I have read the the cancellation policy and agree to the terms.  Signature:                                                   (please type your full name as your signature)

Once your registration form is received, you will be contacted to confirm your course dates and payment.