PLEASE PRINT OUT AND COMPLETE THE FOLLOWING ENROLLMENT APPLICATION FOR THE LIFE & HEALTH OR PROPERTY & CASUALTY INSURANCE PRE-LICENSING COURSE/SCHOOL.
PLEASE MAIL IT BACK WITH YOUR COMPLETE PAYMENT OF $230.00 (if we are to order the required books for you).
$180.00 (if you order the books yourself online at www.bisys-education.com)
***ENROLLMENT APPLICATION***
PLEASE ENROLL ME IN THE FOLLOWING INSURANCE
PRE-LICENSING COURSE:
(LIFE & HEALTH)_____
(PROPERTY & CASUALTY)_______
COURSE SCHEDULED FOR ______ thru________
FULL NAME OF STUDENT-
___________________________________________
COMPLETE MAILING ADDRESS-
___________________________________________
___________________________________________
SSN-_________________ AGE-_______ DOB-______
WHO REFFERED YOU TO US-____________________
__________________________________
DO YOU ALREADY HAVE A TEMPORARY INSURANCE LICENSE?__________
IF YES, WHAT TYPE OF TEMPORARY LICENSE?-
_____________________
WHEN WAS IT ISSUED?________________
WHEN WILL IT EXPIRE?_______________
WHAT COMPANY SPONSORED YOU TO GET YOUR TEMPORARY INSURANCE LICENSE?_______________
ARE YOU NOW WORKING INSURANCE FULL-TIME OR PART-TIME?-____________
DO YOU NOW HAVE ANY FORM OF PERMANENT INSURANCE LICENSE?-_______________
IF YES, WHAT TYPE OF PERMANENT INSURANCE LICENSE DO YOU HAVE?-_____________
WHAT INSURANCE COMPANY ARE YOU WORKING FOR NOW?___________________________
DO YOU WISH TO BECOME AN EXCLUSIVE AGENT FOR OUR COMPANY?___________________________
DO YOU HAVE A GED or HS DIPLOMA?-__________
DO YOU HAVE ANY COLLEGE EDUCATION?-________
IF YES, HOW MANY YEARS AND WHAT MAJOR?
______________________________________
ARE YOU A MILITARY VETERAN OR RETIRED FROM THE US MILITARY?-_______________________
WHEN ARE YOU PLANNING TO TAKE THE ACTUAL STATE EXAMINATION?-_____________________
HAVE YOU TAKEN THE STATE EXAM BEFORE?-
____________________
IF YES, HOW MANY TIMES BEFORE AND WHEN WAS THE LAST TESTING?__________________________
YOUR HOME PHONE NUMBER-____________________
YOUR WORK PHONE NUMBER-____________________
YOUR PAGER OR CELL PHONE NUMBER-____________
YOUR EMAIL ADDRESS-_________________________
**Please complete the above form and mail it with your full tuition payment to:
THE TRINITY LIFE GROUP
200 Knoxville Lane
Oxford, Alabama 36203
attn: Thomas C. Van Dyke
**Please make sure the application and tuition payment is received by The Trinity Life Group well in advance of the scheduled class date. (AT LEAST 30 WORKING DAYS PRIOR TO THE START DATE OF THE CLASS) or sooner if possible.
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