CMAK, Inc. dba/Professional Career
WHERE TRAINING AND BUSINESS CONVERGE TO PRODUCE RAPID RESULTS   CALL 516-483-4000

COURSE REGISTRATION FORM

Upon completion, please forward by our secure email to

pci2win@gmail.com

 

PROFESSIONAL CAREER INSTITUTE, INC.

300 Hempstead Turnpike, Suite 216, West Hempstead, NY 11552

Phone: 516-483-4000   eFax: 1-530-690-8472

Email: pci2win@gmail.com Web: www.professionalcareerinstitute.org

 

 

COURSE REGISTRATION FORM

 

Please complete this form and email, fax or mail to the address above.

Do not send cash in mail and do not email or fax check or money order

 

 

 

Name: Last: ________________________________________ First: ____________________________________ MI: _________

 

Course Name ___________________________________________________________ Start Date________________________

 

Address: _______________________________ City: ________________________________ State:  ________ Zip: ___________

 

Email:  ___________________________________________ Home Ph: ______________________________________________

 

Business Ph: ______________________________Fax: ____________________________Cell: ___________________________

 

Insurance Agent, Broker, Adjuster License Number:

 

LA-_____________; PC-______________; BR-_____________; C1-______________; C3-_____________; LB-______________

 

 

Payment:   Check one:      1Check 1Money Order 1Credit Card:

 

MC_______________ VISA________________ AMEX_______________ DISC_________________

 

 

Name on Card: ________________________________________ Card #: ____________________________________________

 

 

Exp. Date: ____________________ CV# (back or front of card): ___________________ Billing zip code: ____________________

 

 

Amount Enclosed: ____________________________     Make Checks, M/O Payable to CMAK, Inc.