REGISTRATION FORM
                     ( please circle desired course )
Real Estate                   Insurance

Sales                              Title                            Health Only

Broker                            Prop/Cas/Health/Life
General                           
Agency & Ethics                Prop/Cas/Health          Life Only
Management 
                                       Health & Life
_______________________________________________
 Time:        Day               Location:         Northfield
                  Eve                                       West Berlin

Course Start Date:    _______/________/________

Name __________________________________________

Address  ________________________________________

City ___________________ State ________ Zip ________

Phones                  Home ___________________________
                              
                              Cell    ___________________________

                             Work   ___________________________

Firm or Agency ___________________________________

Make checks payable to (and mail to):
                         
                       SJ Prof. School of Bus., Inc
                       P.O. Box 112
                       Northfield, NJ 08225


OR APPLY $ _________________ to my credit card
                   Visa, MaterCard, Discover, AmEx     

Card # _________________________________________

Exp Date _______/_________ cvv2 # ________________
                                                                 (security code)


Signature _______________________________________

Today Date ___________/___________/___________

You may print this form and mail it to the address above or fax it 609-646-3336