H. E. Candage, Inc.

CEU Registration Form

Dates(s) of Class applied for: ______________________________________________________________________________

UTMOST GOOD FAITH I ______ UTMOST GOOD FAITH II ________UTMOST GOOD FAITH III ________ Homeowners _______

NEW PERSONAL AUTO POLICY_________ COMMERCIAL OCEAN MARINE_______ PRE LOSS POST LOSS (3 Hour) ____________

ETHICS III (3 Hour) ________ AGENCY CLAIMS PRACTICE (3 Hour) ___________ E & O CLAIMS PRACTICE (3 Hour)__________

Name: ________________________________________________PRR #_________________________

Name for Name Badge _______________________________________________________________

Company Name: ______________________________________________________________________

Street Address: _______________________________________________________________________

City, State, Zip: _______________________________________________________________________

Telephone: ______________________E-Mail Address_______________________________________

FAX: ________________________________________________________________________________

Home Phone ___________________________Cell Phone ___________________________________

(In the event we need to reach you to make an emergency change only):

The Fee for the Course Including text and refreshments:

Utmost Good Faith $ 149.00 Per Person

Classes are limited to twelve participants. Please enroll early to assure adequate space.

Dress is Casual. Coffee and muffins or pastries will be available in the morning. Lunch is on your own. Parking will be provided depending on facility used. Class Hours are 9:00 AM to 5 PM. Coffee and muffins or bagels will be served in the morning. Lunch is on your own.

Please Mail with the appropriate fee to: H. E. Candage, Inc. Or Provide Credit Card Information Below

Marine Trade Center

2 Portland Fish Pier, Suite 102

Portland, Maine 04101

207-871-1574 FAX 207-871-9015

Credit Card Information

Name on Card:______________________________ Card Number: _____________________________________ Expiration Date: __________

Address: _________________________________________________________________________________________________

(Address needs to Be Exact Billing Address for Card)

Signature: ____________________________________________________________

Cancellations will be accepted until 10 business days prior to course: After 10 days, credits will be applied to future attendance. Please notify us if you need special accommodations for disabilities.

Updated May 10. 2010