|
Please
print the following
about yourself: |
| 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 |
|__|__| -
|__|__|__|__|__|__| -
|__| |
| Firm |
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| |
|
Please
print the following
about
the MCE Course(s) you
want: |
| Format
|
| |__|
7-Hour Elective,
$75
Name
__________________
________________________
Location
________________
________________________
Date
|__|__| -
|__|__| -
|__|__|
Start
Time |__|__| :
|__|__|
AM
|__| PM
|__|
Wknd |__| |
|__|
7-Hour Elective,
$75
Name
__________________
________________________
Location
________________
________________________
Date
|__|__| -
|__|__| -
|__|__|
Start
Time |__|__| :
|__|__|
AM
|__| PM
|__|
Wknd |__| |
__|
3.5-Hour Elective,
$40
(if available)
Name
__________________
________________________
Location
________________
________________________
Date
|__|__| -
|__|__| -
|__|__|
Start
Time |__|__| :
|__|__|
AM
|__| PM
|__|
Wknd |__| |
|__|
3.5-Hour Elective,
$40
(if available)
Name
__________________
________________________
Location
________________
________________________
Date
|__|__| -
|__|__| -
|__|__|
Start
Time |__|__| :
|__|__|
AM
|__| PM
|__|
Wknd |__| |
|
|
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 $15
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.
|
