Continuing Education Registration Form

Student Information (as it appears on your license)*

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Choose Class Date*

Course Selection(s):

MORNING COURSE: Controlling the Ethics of Insurance Fraud Perpetration ($25.00)
AFTERNOON COURSE: Errors & Omissions: Specialized Protection for Entities ($25.00)
MORNING & AFTERNOON COURSES ($50.00)

Course Selection(s):

Attending Lunch*

*Please contact George at 218) 349-0349 or george@zenithautoglass.com to notify us of any allergies or special dietary needs.

NPN (National Producer Number) -same as Wisconsin license number*

Minnesota License Number*

If you do not have a license in this state, please put zeros

Wisconsin License Number*

If you do not have a license in this state, please put zeros

License Type*

License Expiration Date*

Agency/Company*

Address*

Street Address Address Line 2 City State ZIP Code

Address 2

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Alternate Email

Firm*

Payment*

Name as it displays on the card

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If you do not receive a confirmation email, please check your spam folder. Questions? Please contact:
Dryco (218) 628-6101 or office@drycoduluth.com
or George at Zenith Auto Glass (218) 349-0349 or george@zenithautoglass.com

Name as it displays on the check

First Last

Comments

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Continuing Education Signup