Name: ______________________________________________ SS #______________________
Address: ____________________________________________ Phone #___________________
City/Zip: ____________________________________________ Office #___________________
Real Estate Company:___________________________________________________________
Your Pre-Exam Certificate Expires on:_____________________________________________
Tuition: $ _____________ Cash_______ Check #_______ Visa_______ MasterCard_______
Name on Card_________________________________________________________________
Credit Card #___________________________________Expiration Date: ________________
Date: ____________________Signature: ___________________________________________
Submit this registration form and fill tuition to:
ICI, 1830 Craig Park Court, Suite 104, St. Louis, MO 63146
or fax to 314 434 0381