Enrollment Agreement (3B) Video Broker B Application Video Class Information: Enter Begin Class Date: Confirm Begin Class Date: NOTE for BEGIN Class Date above: MUST CONTACT VIDEO COORDINATOR FOR OVERRIDE (choose Today Only) - month and year are already entered; type the DAY only OR choose a date from dropdown box I understand that my access to the Video Course will not be available until I receive my materials and that I must complete all course requirements including final exam before 12/16/21 from the 'Begin Class Date' chosen above. * indicates REQUIRED fields below Student Information: Have you attended classes here before?* YesNo Company Name: First Name:* Middle Name: Last Name:* Nickname: for class purposes Social Security Number:* Street Address: City: State: —Please choose an option—ALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY Zip Code: Cell Phone: Home Phone: Business Phone: Fax Number: Email Address:* How did you hear about us? —Please choose an option—Internet/WebSocial MediaFormer StudentREALTOR®Wyatt SignWord of MouthNewspaperYellow PagesVoice MailOther Payment Information: Payment Choices explained: TUITION options: FULL Amount must be paid to begin VIDEO class. Credit Card is required for all ONLINE submissions. Checks, Cash, and Money Orders accepted at the office or by mail. TEXTBOOK options: Book and materials are included in price of class and are not returnable. {option: Office Pickup} Come by the office to pick up book and materials (no charge) PAYMENT CHOICE : *choose payment: $350 - Full Payment + (option: Office Pickup of Book/Materials) CHARGE to Credit Card: *choose one:VISAMasterCard «« VISA or MasterCard ONLY Card #: * 3-digit security code: * Expiration Date (MM/YY): * Name on Card: * Billing Address Number (used to process credit card): * (numbers ONLY) Billing Zip Code: * Additional Notes to Office Manager (optional): Acceptance of Terms and Policies:* (check both boxes below to accept, after reading the Terms and Policies) Yes, I understand the Terms and Policies as part of this agreement. I am keeping a copy for my records. Yes, I understand #3 of the Terms and Policies that no refund is due once the course materials are mailed or given to me.