|
Please
print the following
about yourself: |
| Social
Security |
|__|__|__|
- |__|__| -
|__|__|__|__| |
| Last
Name |
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| |
| First
Name |
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| |
| M.I. |
|__| |
| Home
Address |
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| |
| City |
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| |
| State |
|__|__| |
| Zip |
|__|__|__|__|__|
- |__|__|__|__| |
| Home
Phone |
|__|__|__|
- |__|__|__| -
|__|__|__|__| |
| Office
Phone |
|__|__|__|
- |__|__|__| -
|__|__|__|__| |
Fax
Phone |
|__|__|__|
- |__|__|__| -
|__|__|__|__| |
| E-mail
Address |
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
@
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| |
|
Please
print the following
about your license(s): |
| RE
Sales License |
|__|__|
- |__|__|__|__|__|__| -
|__| |
| Broker
License |
|__|__|
- |__|__|__|__|__|__| -
|__| |
| Appraiser
License |
|__|__|
- |__|__|__|__|__|__| -
|__| |
| Not
Licensed |
|__|
("X" Here) |
| Firm |
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
|
|
Please
print the following
about
the Home Inspection Course you
want: |
| Start
Date |
|__|__|
- |__|__|- |__|__| |
| Course |
____________________________________________________ |
| Date(s) |
____________________________________________________ |
| Location |
____________________________________________________ |
|
Please
indicate payment
preference: |
| Amount
Due |
$
|__|__|__|__| . |__|__| |
Pay
By ...
(Check One) |
| |__|
Check (Must
accompany form; accepted
by mail only) |
| |__|
Visa
|__|
MasterCard |
| |__|
Discover Card
|__|
American Express |
|
| Card
Number |
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| |
| Expires |
|__|__|
- |__|__| |
| Signature |
____________________________________________________ |
| Please
let us know ... |
| Have
you taken a
course with
Polley before? |
| Yes
|__| No
|__| |
|
|
| How
did you hear
about this
course? |
| Website
|__| Flyer
|__|
Advertising
|__| Radio
|__| |
| Television
|__|
Newspaper or
magazine article
|__| |
| Course
catalog
|__|
Referral from a
colleague |__| |
| Referral
from a broker
|__| Other
______________________ |
|
| Other
information: |
Enrollments
limited. All registrations on a
first paid, first confirmed
basis. No registrations
accepted, nor any place reserved
in a course, until full payment
and information are received.
Polley Associates may cancel
classes due to low enrollment or
unforeseen circumstances. If
this should occur, all fees will
be refunded. If a student
voluntarily withdraws from a
class at any time, no refund
will be given. Instead, the
tuition paid can be credited
toward fees for a future Polley
Associates' course, which must
be completed within six months
of the originally scheduled
course. There is a $20 charge
for returned checks. All
policies subject to change
without notice. Other enrollment
and refund limitations or
exceptions may apply.
If you have special needs due
to a handicap or disability,
Polley Associates can help!
Please let us know.
Here are your options for
this form, once it's completed.
Please print (do not write) all
information for readability. 1)
Fax it toll-free to Polley
Associates at (888) 941-9500; or
2) Mail it to Polley Associates,
3544 West Chester Pike, Suite
200, Newtown Square, PA, 19073;
or 3) Talk to someone in person
by calling Polley Associates at
(610) 353-6776 or toll-free at
1-(800) 220-2789.
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