NAIFA - Palm Beaches

ONLINE REGISTRATION FORM
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We gladly accept

For registration information, please call Online Training at (561) 283-0333.

Notice: The information entered on this registration is processed through OnLine Training's secure server for the Palm Beaches Association of Insurance and Financial Advisors. It is sent directly to the college of your choice for enrollment. You will receive an e-mail with your access to the course and other important information within 24 to 48 business hours of receipt.

Course Information Choose your test date (if applicable) for the desired college and course:
2-20 P&C Pre-Lic	20-44 Pers Lines	4-40 to 2-20 Conv	4-40 RCSR Desig	ACA Desig	CE Life	CE Health	CE Ethics	CE Health Svgs Acct	CE Flood Ins Cncpt	CE Ethics & the Client
Broward College
$565	$395	$489	$395	$395	$84	$84	$30	(N/A)	(N/A)	(N/A)
Miami-Dade College
$395	$350	$295	$315	$315	$88	$88	$25	$25	$25	$25

Student Information
(bold entries are required)

Contact

Student's Full Name:	*(Required)*
E-mail Address:	*(Required)*
Mailing Address:
Street:	*(Required)*
City:	*(Required)*
State:	*(Required)*
Zip code:	*(Required)*
Contact Phone, with Area Code:	*(Required)*
Alternate Phone, with Area Code:

Required by Colleges

Social Security Number:	*(Required)*
Date of Birth: (day/mo/yr)	*(Required)*
Country of citizenship:	*(Required)*
Gender:	Male Female *(Required)*

The following information is requested by the U.S. Office of Education - please select one: (Required)
	White, Non- Hispanic
	Asian or Pacific Islander
	American Indian or Alaskan Native
	Black, Non- Hispanic
	Hispanic
The following information is required for some courses - please select one: (Required)
	I am a high school graduate.
	I am not a high school graduate.
Residency Statement: (Required)
	I certify that I have resided in Florida as a permanent resident for the past twelve consecutive months or longer or otherwise meet the residency requirements outlined in the law of the State of Florida.
	I have not resided in Florida as a permanent resident for the past twelve consecutive months and I do not meet the residency requirments.
I declare under penalty of perjury punishable by law as a misdemeanor under Section 837.08, F.S., that the forgoing is true and accurate. I do. I don't. (Required)

Purchase Information
(bold entries are required)

Type of Credit Card:	*(Required)*
Credit Card Number:	*(Required)*
Expiration Date: (mo/yr)	*(Required)*
Exact Name on Credit Card:	*(Required)*