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PENNSYLVANIA CE REGISTRATION FORM


To register for multiple locations, we request that you print this form below, fill it out, and send it to Wise Education Inc. by fax or mail. Thank you.
Wise Education, Inc.
1501 Cobblestone Ct.
Thorofare, NJ 08086
Fax: 856-384-8414

DATE_______ CITY_______________________ TOPIC___________________ TIME_______ CR'S ___ $____
DATE_______ CITY_______________________ TOPIC___________________ TIME_______ CR'S ___ $____
DATE_______ CITY_______________________ TOPIC___________________ TIME_______ CR'S ___ $____
DATE_______ CITY_______________________ TOPIC___________________ TIME_______ CR'S ___ $____
Tuition Total $________  # of Credits_____________
PAYMENT OPTIONS:
____Check #_________ Check amt. $____________
____Visa    ____MC    ____Discover
Expiration Date _____/______(Required)
CC #_______________________________________

Cardholder Name_____________________________
                                                      (Please print)
Signature____________________________________

 Comments:__________________________________

____________________________________________
Wise Education of PA  800-577-9888
wise.education@verizon.net

PLEASE ATTACH MEMO AS TO ANY SPECIAL NEEDS

 
FIRST_______________________MI____
LAST____________________________Jr / Sr / III
PA LIC#___________________________
PA INSURANCE LIC EXP DATE  _  _  /  _  _  /  _  _
DATE OF BIRTH   _  _  / _  _ /  _  _
SOC. SEC. #   _  _  _  /  _  _  / _  _  _  _
HOME ADDRESS__________________________
CITY/ST_______________________ZIP_________
HOME PHONE  (  _  _  _  ) _  _  _  -  _  _  _  _
MOBILE PHONE  (  _  _  _  ) _  _  _  -  _  _  _  _
E-MAIL___________________________________
BUS FIRM________________________________
BUS PHONE  (  _  _  _  ) _  _  _  -  _  _  _  _
BUS FAX  (  _  _  _  ) _  _  _  -  _  _  _  _

BUS ADDRESS___________________________
CITY/ST_______________________ZIP_________
 Please make a copy of this form and mark your calendar.
No CE confirmations mailed.

 
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