CHARTERED BENEFIT CONSULTANT
OPEN ENROLLMENT 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 ONE WEEK 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 LEVELS OF $499.
Name: ___________________________________________ (as you want it to appear on your certificate)
Address: _______________________________________________
_______________________________________________
Phone: _______________________________ Fax: _____________________________________
Email Address: _____________________________________________________
Please register me for the seminar version CBC™ class # __________ (Per calendar)
(Please check one)
_____ I DO WANT CE CREDITS FROM THIS CLASS
_____ I DO NOT WANT CE CREDITS FROM THIS CLASS
_________________________________________________ ____________________________________________________
Name Signature
_________________________
Date
REFERRED BY:
____________________________________________________________
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PAYMENT OPTIONS
(PLEASE NOTE: Your payment WILL NOT be transacted until after the “Discount Deadline” has passed
in the event the class you have selected is cancelled.)
(Check Options 1 or 2)
Check or Money Order _____ Credit Card (All options)______
Option 1: _____ I have enclosed a check, money order or credit card information for $399 (if not timely, $499) as full payment of tuition.
Option 2 requires completion of credit card information below
Option 2: ______ I have enclosed a check, money order or credit card information for $200 (or if not timely, $250) and understand that you will bill my credit card for the balance of $199 (or if not timely, $249) 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 # ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Expiration date ___ ___ / ___ ___
Deposit Amount: ____________ Signature __________________________________
Date________________ Printed Name as it appears on Card
___________________________________________
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You may either mail the completed form to the address below or fax to 630-858-2130
THE REGISTRATION MATERIALS NEED TO BE IN THE NAABC OFFICE BY THE DISCOUNT DEADLINE DATE OF ONE WEEK PRIOR TO THE FIRST DAY OF CLASS TO ASSURE OPEN ENROLLMENT TUITION RATE (normal tuition is $499)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
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