Central Alabama Real Estate Academy Montgomery Alabama

4180 Carmichael Rd. Montgomery, AL 36106	Director: Dan Stalling Instructor/Administrator: Jim VanErmen
Registration Form	date: __________

Course Name: __________________________________________

Start date and end date of Course: __________________________

Name: first ___________, middle ____, last ____________________

Social Security Number: _________ - ______ - __________ OR
(Required to apply for Real Estate License)
Salesperson State License Number: ____________________
(Required to apply for Post License Course)

Address: __________________________________________________

Phone # day __________, night __________, cell/pager ___________

E-mail address: _____________________________________________

Company affiliation (if any) : __________________________________

ADA / Disability requirements: ________________________________

By signing this form I certify the above information is correct to the best of my knowledge and I have read the Course Description Sheet and have accessed a copy of the class schedule. The administration fee is required to process this application and remaining tuition fee is required prior to the start of the first class.

Signature: ______________________________ date: ________

School Policy: Central Alabama Real Estate Academy will not discriminate on the basis of race, color, sex, religion, national origin, handicap, ancestry, sexual orientation, marital status, and familial status in the establishment of fees, entrance qualifications or standards for successful completion of any course.

For administrative use:

Date application received: ______________ Registration fee received: yes no

Application number: ___________ Tuition fee received: yes no