Registration

Networx Registration Form
This form should be completed prior to submitting your class fees. Once you have completed this form and we have received your required payment via paypal or mail, you are considered registered for the class. If you are taking an on-line class, the materials will be email to you within 24 hours of cleared payment.

*indicates required fields

*First Name:

*Last Name:

*Street Address:

*City:

*State:

*Zip:

*Phone Number:

*Alt. Phone Number:

*Email Address:

*Last 5 numbers of your SS#:

*Date of Birth:

*Class(es) you are enrolling in:

*Face to Face, On-line or Home Study:

Face to Face
On-Line
Home Study/Correspondence

*Do you agree to the class registration policies?:

Yes
No

Questions/Comments:

*Please type your first and last name.:

*How will you be paying for the class(es)?:

On-line
By mail

Will someone else be paying for your class(es)?:

No, I will pay
Yes, someones else

If someone else will be paying, who?:

The last 5 number of your social security number only applies to Wisconsin residents who wish to receive a certificate from the registry. By answering yes and typing your name, you are agreeing to all of Networx registration and class policies. After you have completed this form click on the SUBMIT button.

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