Dick's Code Class Registration Form

Add number next to License(s) you wish to renew

First Name *

Middle Initial

Last Name *

Generation i.e. Jr, 2nd, 3rd , etc

Street Address *

City *

State *

Zip Code *

Phone Number

Work Phone Number

Company Name

City

State

Email Address *

CHOOSE FROM ONE OF THE FOLLOWING OPTIONS (PART #1)

* 🛈

CHOOSE FROM ONE OF THE FOLLOWING OPTIONS (PART #2)

* 🛈

Is there any questions you need to ask ?

Cost of the class is as follows: 21 hrs $250.00 Retirees $220.00 / 15 hrs $175.00 Retirees $155.00 / 6 hrs $75.00 ******* Retirees $65.00 Credit Card add 3%

by selecting YES below,

You agree to attend the class selected

and to pay the Fee associated with it

*

YES