Certified Insurance Service Representatives (CISR)
Registration Form

Fields in Yellow are Required

YOUR INFORMATION

Name:

First Name M.I. Last Name Suffix

Designations:

Agency/Company:

Address:

City:

State:

ZIP:

Phone:

Cell Phone:

Fax:

Email Address:

License Number:

Birth Date:
,

CLASS REGISTRATION
This is my first CISR class This is my annual CISR designation update I am working towards CISR Elite Designation.
To register for a class, click the checkbox next to the Course Title and then select the Class Date and City
Course Title:	Class Date and City:
Personal Residential
Commercial Casualty 2
Elements of Risk Management
Other Personal Lines
Personal Auto
Commercial Property
Commercial Casualty 1
Agency Operations
Life and Health Essentials
William T. Hold

Registration Fee is $175.00 per Class

NEW CANCELLATION POLICY FOR 2023 — Cancellations received within 3 days of the class will incur a $25.00 non-transferable fee. No-shows will forefit the entire registration fee.

PAYMENT INFORMATION

Payment Information: Payment is due prior to the class — late payments will be assessed a $25 fee.

Method of Payment:
Visa MasterCard American Express Check

A 3% Processing Fee Will Be Charged To All Credit Card Transactions.

Registration Fee for Classes Selected Above: $0.00

By checking this box and submitting this form, you authorize and commit to the payment of $0.00 for CISR class registration, per the cancellation policy described above.

Certified Insurance Service Representatives (CISR) Registration Form

Fields in Yellow are Required

Certified Insurance Service Representatives (CISR)
Registration Form