Class Registration

Name :

Address :

Address Line 2 :

City or Town :

State/Province :

Zip / Postal Code

Phone

Fax

Your Comments :

LICENSE REF # (CE ONLY) :

SS# :

DOB :

LIC EXP. DATE (CE ONLY) :

FIRM NAME :

FIRM ADDRESS :

FIRM BUILDING :

FIRM PHONE :

FIRM FAX :

PLEASE REGISTER ME FOR : LIFE /HEALTH, PERSONAL LINES, PROPERTY / CASUALTY, TITLE, OTHER, LIMITED REP

PLEASE REGISTER ME FOR: CONTINUING EDUCATION (COURSE NAME) :

DEPOSIT : $ I UNDERSTAND THE BALANCE MUST BE PAID BY THE FIRST DAY OF CLASS.

BALANCE DUE : $

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IN PERSON PRE-REGISTRATION: is available at our Union training center during the following business hours: Monday thru Friday from 9:00 am to 4:00 pm

SAME DAY REGISTRATION: Will be accepted on the first session of class, provided ther are openings for additional students. Pre-Registration is preferred. Call (908) 964-6500 to check the status of the course you are interested in.

Detach and Mail/ or Fax deposit to : YOKELY INSURANCE INSTITUTE, 1235 Morris Ave , Union , NJ 07083
PHONE: 908-668-8422 FAX: 908-668-8455 EMAIL: Karen@yokelyinsurance.com

1235 Morris Avenue
Union, New Jersey 07083
Phone (908) 964-6500, Fax (908) 668-8455

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