To register for multiple locations: Go to registration form To register by mail or fax for this location ONLY, follow these steps: 1. Print this page. 2. Check desired classes. 3. Fill in required information and send to: Wise Education, Inc. 1501 Cobblestone Ct. Thorofare, NJ 08086 Fax: 856-384-8414 Tuition Total $________ # of Credits______________ PAYMENT OPTIONS: ____Check #_________ Check amt. $__________ ____Visa ____MC ____Discover Expiration Date _____/______(Required) CC #_____________________________________ Cardholder Name____________________________ (Please print) Signature___________________________________ Comments:_________________________________ __________________________________________

FIRST_______________________MI____ LAST____________________________Jr / Sr / III DATE OF BIRTH _ _ / _ _ / _ _ HOME PHONE ( _ _ _ ) _ _ _ - _ _ _ _ MOBILE PHONE ( _ _ _ ) _ _ _ - _ _ _ _ HOME ADDRESS__________________________ CITY/ST______________________ZIP_________ BUS FIRM________________________________ BUS PHONE ( _ _ _ ) _ _ _ - _ _ _ _ BUS FAX ( _ _ _ ) _ _ _ - _ _ _ _ BUS ADDRESS___________________________ CITY/ST______________________ZIP_________ E-MAIL___________________________________ Please make a copy of this form and mark your calendar. No CE confirmations mailed. PLEASE ATTACH MEMO AS TO ANY SPECIAL NEEDS

I wish to earn CE credits for the following state(s):

NJ State Lic #______________ Exp _________

PA State Lic #______________ Exp _________

NY State Lic #______________ Exp _________