ADVANCED CHARTERED BENEFIT CONSULTANT

                                                                    REGISTRATION FORM

             Thank you for your interest in the ADAVANCED CHARTERED BENEFIT CONSULTANT (ACBC) course and, more specifically, your interest in furthering your knowledge and expertise in Consumer-Driven Health Plans.  Please complete the following information and return to

us with payment or payment arrangements AT LEAST SEVEN (7) DAYS BEFORE THE CLASS.   If you do so, the total tuition is $200.  PAYMENTS RECEIVED AFTER THAT DATE WILL REVERT TO THE NORMAL TUITION LEVEL OF $250.  THIS COURSE IS VALUED AT 8 CE CREDITS IN MOST STATES (9 IN NY). 

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Name: ______________________________________________________________________ (as you want it to appear on your certificate)

 

Address: _______________________________________________  

             _______________________________________________

 

Phone:  _______________________________   Fax: __________________________

 

Email Address: _____________________________________________________

Home State__________________

Next License Renewal Date (mm/yyyy) _____ ____/_____ ____ ____ ____

PLEASE NOTE:  When filing CE credits, some states require the use of Social Security Numbers, or separate State Insurance License Numbers, and others require National Producer Numbers (NPNs) while still others use System IDs. 

PLEASE VERIFY WHICH NUMBER YOUR STATE REQUIRES BEFORE COMPLETING THIS FORM!!!

  (Please underline which number is being entered)

Social Security          State Insurance License Number          NPN          System ID   

         

 

                

ACBC CLASS DATES FOR 2011:
  1 January 25th & 26th (9 am to 1 pm CST both days)   4  June 7th (9 am to 5 pm CDT)
  2
March 9th (9 am to 5 pm CST)   5  August 9th (9 am to 5 pm CDT)
  3 April 20th (9 am to 5 pm CDT)   6  October 10th (9 am to 5 pm CDT)
Please register me for ACBC class # ______ 

Your CBC listing and your NAABC membership will be extended for TWO YEARS from the date of class completion or for TWO YEARS from the date of current term’s expiration, whichever later.

 

PAYMENT OPTIONS

(please check option used)

Payment option 1: _____ Check or Money Order   (PLEASE NOTE:  IF MAILING A CHECK OR  MONEY ORDER, PLEASE ALSO FAX THIS FORM TO 630-858-2130 AT LEAST SEVEN DAYS BEFORE  THE CLASS.)        

Payment option 2: _____ Credit Card or Debit Card (We accept Visa, MasterCard and AMEX credit and debit cards)

____________________________________________

signature
If Payment Option # 2 is selected, please complete the following:

Card #

        XX         XX         XX        

   

Expiration date: (MM/YY)
/

 

Payment Amount:      

$        
.
    

Signature: ______________________________________   Date: ___ ___ / ___ ___ / ___ ___

 

Printed Name as it appears on Card _______________________________________

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YOU MAY EITHER MAIL, FAX OR SCAN AND EMAIL THE COMPLETED FORM TO THE ADDRESS BELOW:

THANK YOU FOR YOUR PARTICIPATION AND FOR YOUR INTEREST IN THE EDUCATION THIS CLASS WILL PROVIDE!

The National Association of

Alternative Benefit Consultants

435 Pennsylvania Avenue,  Glen Ellyn, IL 60137-4401

Toll Free: 800-627-0552   Fax: 630-858-2130  Email: NAABCX@aol.com