CHARTERED BENEFIT CONSULTANT

REGISTRATION FORM

 

              Thank you for your interest in the Chartered Benefit Consultant (CBC)™ advanced designation offering.  Please complete the following information and return to us with payment

or payment arrangements AT LEAST TEN DAYS PRIOR TO THE FIRST DAY OF CLASS.   If you do so, the total tuition is $399.  PAYMENTS

RECEIVED AFTER THAT DATE WILL REVERT TO THE NORMAL TUITION LEVEL OF $499.

TO REGISTER ON-LINE, CLICK HERE

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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 Insurance CE credits, some states require the use of Social Security Numbers, others require separate insurance license numbers, 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:

License #

 

Please register me for the:

check one    class type                                  to be held at (city, state)                                          to be held on

  seminar verson    
  interactive webinar version
N/A
  

PLEASE NOTE:  Unless otherwise requested or notified prior to the class, we will file the appropriate number of CE credits with your home state insurance department for attending this class.

                                                 

 Signature:  ______________________________________________     Date:  ___ ___ /___ ___

REFERRED BY:  _______________________________________________

 

 

 

Payment Options

Check or Money Order _____ (check options 1 or 2)                                                                                          Credit Card _____ (all options)

Option 1 _____ I have enclosed a check, money order or provided credit card information for $399 as full payment of the truition.

Option 2 _____ I have enclosed a check, money order or provided credit card information for a deposit of $200 and understand that you will bill my credit card for the balance of $199* WITHIN 30 DAYS OF TODAY'S DATE

___________________________________

Signature

For Option # 2, completion of the credit card information below is required.  YOUR CREDIT CARD WILL ONLY BE BILLED IF YOU AUTHORIZE NAABC TO BILL YOUR CREDIT CARD FOR YOUR PAYMENT.

Please circle card type:  AMEX    Visa    MasterCard

Card #
XX
XX
XX

Expiration Date:  (mm/yy)                                                                   

    //    

   

 Payment Amount:

$         .  

Signature: ________________________________________          Date:  ___ ___ / ___ ___ / ___ ___

Printed Name as it Appears on Card: ______________________________________________________________

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

THE REGISTRATION MATERIALS NEED TO BE IN THE NAABC OFFICE AT LEAST SEVEN DAYS PRIOR TO THE FIRST DAY OF CLASS TO ASSURE OPEN ENROLLMENT TUITION RATE UNLESS PRIOR ARRANGEMENTS HAVE BEEN MADE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

                                                             THANK YOU!

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The National Association of

Alternative Benefit Consultants

435 Pennsylvania Avenue,  Glen Ellyn, IL 60137-4401

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