H.E. Candage, Inc. - Boot Camp Registration Form

H. E. Candage, Inc.
Insurance Boot Camp Registration Form

Date(s) of Class applied for:	_________________________
Your Name:	_________________________
Company Name:	_________________________
Street Address:	_________________________
City, State, Zip Code	_________________________
Telephone Number:	_________________________
E-mail Address:	_________________________
Fax Number:	_________________________
Home Phone:	_________________________
	(In the event we need to reach you to make an emergency change only)

The Fee for the Course (Five Days) Including Text Book and Refreshment Breaks is $595.00.

Classes are limited to twelve participants. Please enroll early!
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.

Please Mail with the appropriate fee to:

H. E. Candage, Inc.
Marine Trade Center
2 Portland Fish Pier, Suite 102
Portland, Maine 04101
207-871-1574 FAX 207-871-9015

Or Provide Credit Card Information Below

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.
No Credit will be given for the $125.00 fee for Class Materials.