Fax or Mail-in Registration Form

Last Name: _____________________ First Name ____________________________ MI ____

Company Name: _____________________________________________________________

Street Address: _______________________________ City: ___________________________

State _____ ZIP _________________

Home Phone (       ) ___________________ Business Phone: (        ) __________________

Fax Number: (        ) __________________ E-mail address: __________________________

Social Security Number: _____________________________________

Name of course you are registering for: ___________________________________________

Start Date: ___________________________ Location: _____________________________

Amount Remitted $_________________

Post Licensing 30 Hours (All five courses Pl-1, PL-2, PL-3, PL-4 and PL-5) $295 
Pre-Licensing 60 Hours $499
Agency and Law Update $49
C-CREC $299 

Method of payment(circle one) : Visa     Master Card      Check

Card Number: _____________________________________ Exp. Date:__________

Signature (as it appears on card): _________________________________________

FAX Number 803-781-5095      Office 803-234-8824

Mailing address:
Doug Schmitt Seminars
116 Averill Lane
Irmo, SC 29063