ࡱ> ?A> @ Z bjbj $؝؝X  <4 v \|'0Ws$,"R~$>  W'WW 0 W 8 WU  }P bs4mF 0v u$F$} $ }xMtQ  D  Intellipass TM -Vancouver Insurance Prelicense & Continuing Education 3925 NE 72nd Ave., Suite 101, Vancouver, WA 98661 Phone: (360) 750-5633 ( Fax: (360) 571-4671 ( E-mail: vancouver@intellipass.com Student Registration / Payment Form Please Print Clearly Last Name: First Name: Middle Initial: Preferred Name: Managers Name: Birthdate: Company Name: Home Add.: Company Address Apt./Unit#: Suite or Bldg: City/State/Zip: City, State, Zip: Home Phone: Business Phone: E-mail: Cell Phone:  Live Lecture Class (check one) Payment Information  FORMCHECKBOX  (VLDR) Life, Disability & Code Amount Paid:  FORMCHECKBOX  (VLR) Life and Code ONLY  FORMCHECKBOX  Paid Check No:  FORMCHECKBOX  Cash  FORMCHECKBOX  (VDR) Disability and Code ONLY  FORMCHECKBOX  CC#  FORMCHECKBOX  (VPCR) Property, Casualty & Code Exp. Date. V Code  FORMCHECKBOX  (VPR) Property and Code ONLY Name on CC  FORMCHECKBOX  (VCR) Casualty and Code ONLY Signature  FORMCHECKBOX  (VR) Washington State Code ONLY Billing Address: Class Start Date _______________ For Federal Way Office Use Only Enrollment Date: Completion Date: Student Number: Processed by: Password/Notes: Last Name: ______________________________ First Name: ______________________________  .LVX  ̿zqd^QFh hKOJQJh hKCJOJQJ h"CJhKh"OJQJ^JhH5OJQJhr5OJQJ j&hyG5OJQJhW6|5OJQJhW6|hW6|5H*OJQJhW6|hW6|5OJQJh"56CJOJQJh]56CJOJQJh"56OJQJ h">*h#h#5>*CJH* h#>*h"jh"UmHnHuL : _ } o 8:D%EdX]^Egdg 8D%EdX]^Egdg 8D%EdX]^Egdg  * X D%B@EdX]^EgdgxhgdK $ Ha$gdW6| H  Y   ' ( 8 9 : D L M ] ^ _ k m { |        ! " 4 ˿v#hyGh@35CJOJQJ^JaJhyG5CJ OJQJ^JhKh"5CJ OJQJ^J3jhKhyG5CJ OJQJU^JmHnHuh hK6OJQJh]OJQJmHnHuhKOJQJhgOJQJmHnHuh hKOJQJhgOJQJ*   d X  b {l HD%dh<gdW6| H zD%@dh<gdS HD%dh<gdS HPD%@Bdh<gdS HD%dhgdg HxgdyG 8D%E]^Egdg 8D%EdX]^Egdg 4 @ A P c d e s t u w x ±rcrSrSc@c%jh~7h"CJOJQJUaJh~7hg5CJOJQJaJh~7h"CJOJQJaJh~7h"5CJOJQJaJhKh"5CJOJQJ'jh^9h^9CJOJQJUhKh"CJOJQJ!jhKh"CJOJQJU h"5CJ#hyGh"5CJOJQJ^JaJhKh"5CJOJQJ^J h"CJhKh"CJOJQJ^J        ? @ N O P U V X Y g DZǢnjv`Ph~7hg5CJOJQJaJ+jHh^9h^9CJOJQJUaJ+jh^9h^9CJOJQJUaJ+j^h^9h^9CJOJQJUaJh~7hSCJOJQJaJ+jh^9h^9CJOJQJUaJh~7h"CJOJQJaJ%jh~7h"CJOJQJUaJ+jth^9h^9CJOJQJUaJg h i k       + ǷǨǒǁǨk[Ǩh~7h"6CJOJQJaJ+jh^9h^9CJOJQJUaJ h~7h"@CJOJQJaJ+j2h^9h^9CJOJQJUaJh~7hSCJOJQJaJh~7h"5CJOJQJaJh~7h"CJOJQJaJ%jh~7h"CJOJQJUaJ+jh^9h^9CJOJQJUaJ+ , - N ^ a b g r ǸwjRD7-hCJOJQJhKh"OJQJ^JhKh"6OJQJ^J/jhKh"5OJQJU^JmHnHuh~7hCJOJQJhCJOJQJaJhh5CJOJQJaJh@35CJOJQJaJh"CJOJQJaJhW6|CJOJQJaJh~7h#CJOJQJaJh~7h"CJOJQJaJ%jh~7h"CJOJQJUaJ+jh^9h^9CJOJQJUaJb  W X Y Z  8p  D%xgd.W4 HD%xgd.W4 HD%ZZxgd.W4 H@xxgdyG$ HD%xa$gdyG  W Y Z h"hKh"OJQJh~7h"OJQJhCJOJQJh~7h"CJOJQJh.W4CJOJQJ/ =!8"#$%tDeCheck1tDeCheck3vDeCheck11vDeCheck11tDeCheck5vDeCheck11tDeCheck9tDeCheck9vDeCheck10vDeCheck10$8@8 Normal_HmH sH tH p@p Heading 1,Chapter Headers$$@&a$56;CJ$KH@ Heading 2,Section Headers*$$$d%d&d'd-D$@&a$ 56B*CJ\@\ Heading 3,- Subheads $@& 5:>*CJN@N Heading 4$@& H56CJHOJQJ:@: Heading 5$@&56f@f Heading 62$$xx$d%d&d'd-D @&a$5CJ$B@B Heading 7$$@&a$5CJX@X Heading 8$$ H@&a$56CJOJQJP @P Heading 9 $$ Hx@&a$ 56CJ DA@D Default Paragraph FontViV  Table Normal :V 44 la (k(No List 8O8 ans & F  CJDOD questionhx^h`CJO roman~ & F vv>T^v`VO"V title2&$h0*&#$+D/a$ 56CJ0<O2< title3 $xa$ 56CJO Bullet Header 2 & F 8p h>Th^h` 5>*CJO Bullet Text 1 & F h8hx>Th^h`CJBOQbB Bullet Text 2<^Or Bullet Text 3p & F8>Th^8`CJO Bullet Text 4 & F h8x>Th^`CJ4 @4 Footer  !4@4 Header  !OQ Number Text 1d & F>Th.O Number Text 2e>Th)^O Number Text 3e8<>Th)^8O Number Text 4a>Th)^.)@. Page NumberHOH Text 1  8p CJROR Text 2'! h8hx^h`CJLOL Text 3"" h8hx^hCJH2H @f Balloon Text#CJOJQJ^JaJWZ WZZ$L :_}d XbWX[80000P0H0000000000000 000 00h0000 0P@00p :_}d XW[Oy00Oy00Oy00Oy00Oy00Oy00Oy00Oy00Oy00Oy00Oy00Oy00Oy00Oy00Oy00Oy00Oy00Oy00Oy00Oy00Oy00Oy00Oy0000 Oy000p 4 g + Z   b Z  Y dt ?OXh,ZG$G$G$G$G$G$G$G$G$G$H34 @\3(  V  C )"N  S  N  S  b   C " N  S  B S  ?Z &4)z.t'@8tbctHh%ctH2h%tCheck1Check3Check9eY[ui[ L# "  # TG  D l" $+ $ $ L  ̄  LLjuy44?[     hsw~~>DD[  =*urn:schemas-microsoft-com:office:smarttags PlaceType=*urn:schemas-microsoft-com:office:smarttags PlaceName9*urn:schemas-microsoft-com:office:smarttagsplace> *urn:schemas-microsoft-com:office:smarttags PostalCode9 *urn:schemas-microsoft-com:office:smarttagsState8 *urn:schemas-microsoft-com:office:smarttagsCity: *urn:schemas-microsoft-com:office:smarttagsStreet;*urn:schemas-microsoft-com:office:smarttagsaddress9 *urn:schemas-microsoft-com:office:smarttagsphone $6571$$$$6750$$$o:ls phonenumbertrans     `i[r)1[333bV[[{s;NY^`.{s;&(.W4jFyGK&)N?]@fgr lW6|S#@3]^9 E]H"r~7j@^^` ^^Z@@UnknownGz Times New Roman5Symbol3& z Arial;WingdingsA& Arial NarrowK,Bookman Old Style5& zaTahoma"qhF&F B B !24d 3QH)?r lpaulhpaulh Oh+'0|  , 8 D P\dltpaulh VancouverClassRegistration08paulh5Microsoft Word 10.0@hx@¤@Qä@"B՜.+,0 hp|  PEC   Title  !"#$%&'()*+,-/012345789:;<=@Root Entry FЦBData 1Table$WordDocument$SummaryInformation(.DocumentSummaryInformation86CompObjj  FMicrosoft Word Document MSWordDocWord.Document.89q