Registration Form for Designation Courses.

All fields must be filled out to be registered for a class!

Name:	LAST,        FIRST           MI        (ALL IN CAPS) NAME MUST BE AS IT APPEARS ON YOUR LICENSE!
Address:
City:
State:
Zip Code:
Phone:
Class NAME: DATE:	(Enter Date of Class)
2ND Class NAME: DATE:	(NAME Of CLASS) (Enter Date of 2ND Class)
License #	Mandatory if you are a licensed agent
Email:

 

Payment must be received prior to start of class.
Make Checks Payable To:
The Market Place Academy
Drop off at 1902 Eastwood Rd. Suite 104
Wilmington. NC 28403

or

Mail to P.O. Box 505
Wrightsville Beach, NC 28480
Attn: Eva Stone

or

To use a Credit Card call Eva Stone 910-256-7779

Cancellation Policy for Designation Classes
$25 cancellation fee if cancelled within 10 days of the course.
No Refunds after that date.