Form

Full Name*

First Name Last Name

Social Security # LAST 4 digits only*

Birth Date*

Month Day Year

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number*

- Area Code Phone Number

E-mail*

Courses Selected*

Term Selected*

2017 Spring Session- January 1 to May 14 2017 Summer Session-May 15 to Aug 31

....

Amount $:Choose One*

$300.00- FIRST Educational Resources Courses $300.00- Smekens Education Courses $350.00 -DISTANCE/Correspondence Courses $450.00 -ONLINE Courses $450.00 -ONSITE TBT Courses $450.00- Infinitec Courses $450.00 -Richard Byrne Graduate Webinar Courses

Payment Method*

Visa MasterCard American Express Discover

Credit Card Number*

Exp. Date (MMYYYY)*

CVC # 3 digit code on back of Visa /MC. 4 digit code on front of AMEX*

School Where Employed*

Group Discount Rate*

Individual Group of 3-5 $20 off Group of 6-8 $30 off Group 9 or more $40 off

Group Members Names

FORMAT-Choose One*

DISTANCE/CORRESPONDENCE ONLINE Courses ONSITE 599 TBT Course Smekens Education Course FIRST Ed Resources Course Infinitec Video Course Richard Byrne Graduate Webinar Course

Referred By

Grade & Subject Taught*

Promotional Code

Transcripts/ Teaching Certificates*

Yes-The College has my permission to look up No- I will send in before course starts- email to: [email protected]

How Did You Hear About Us*

Google Email from us Online Ad Colleague Referral Smekens Education Referral Email Infinitec Email or Conference FIRST Educational Resources Email/Webpage