Independent Career Institute
Real Estate Training School
Accredited by the Missouri Real Estate Commission

ENROLLMENT FOR SCHOOL STARTING ON:_____________________________
                                                                                                  (month / day / year)

Check One:        SALESPERSON______________  BROKER____________________
Check One:        DAYS_______________________  NIGHTS_____________________

Name:_____________________________________________________________________________

Address:___________________________________________________________________________

City/State/Zip:______________________________________________________________________

Phone Number: (day)_____________________________(night)_______________________________

Date:_______________________Signature_______________________________________________



    Total Registration And Tuition Amount:$__________________ Check /Money Order # ____________
    Name on Credit Card: ________________________________________________________________
    Credit Card # ______________________________________________________________________
    Visa: _______ Master Card:_________Expiration Date:______________________V-Code:_________ ( #'s on back of card )

    Date:_______________________Signature:_____________________________________________

    (If Sponsored)    Broker / Company Name:_______________________________________________
 

Mail To: Independent Career Institute
                1830 Craig Park Court, Suite 104
                St. Louis, Missouri 63146
Phone:   314 - 434 - 2425

Fax To:  314 - 434 - 0381

NOTE:    Certain Criminal Convictions MAY prevent you from receiving or retaining a real estate license.

This enrollment form must be submitted along with full registration and tuition in order to get pre-registered
and enrolled in a Salesperson or Broker Course.

REFUND POLICY: The registration fee ($100.00) is NON-REFUNDABLE.  When written notification for cancellation of
an enrollment is received at the ICI office, and postmarked at least ten (10) days PRIOR to course commencement, the
tuition charge will be refunded.  Students withdrawing AFTER the aforementioned ten (10) day period will receive no
refund.  No refund will be made for students who fail to attend the minimum number of required hours.  Such students
may attend any missed classes during the next available scheduled courses within six (6) months of the course
originally enrolled in.

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