ITI Register

Class Date Request:		Location:
Second Date Choice:		Location:

(Last Name)	(First Name)		(MI)
Agency / Company Name
Insurance License Number:	LA / LB
Please Provide Individual License Numbers only	PC / BR
	PA
Mailing Address:	Office Address:



Daytime Phone Number	Fax Number

Nighttime Phone Number	Email Address

Your Comments:

You may also print this form and fax your registration 518-758-6693.
The Insurance Training Institute accepts personal and business checks the day of class,
but we are unable to process Credit Card transactions. PLEASE DO NOT MAIL CHECKS!

Robert T. Secovnie
Insurance Training Institute ( I T I )
20 Spruce Street
Valatie, NY 12184

REGISTRATION IS ON A FIRST COME FIRST SERVE BASIS