Central Alabama Real Estate Academy Montgomery Alabama

4180 Carmichael Rd. Montgomery, AL 36106	Director: Dan Stalling Instructor: Jim VanErmen Administrator: Jon VanErmen
Registration Form (print and mail)	date: ______________

Course Name: __________________________ Course dates: ______________

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: ________________________________
For the Pre-License course, I will read the 6 articles as provided on the website
prior to attending the first class - circle one Yes No

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. If class size is limited, registrations will be processed "as received".

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/Time application received: _______________ Registration fee received: yes no

Application number: ________ Tuition fee received: yes no Online Form: CAREA0621