Company Name:
Name of Person Authorized to sign Company/Personal Check:
Company Address:
City:
State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming Armed Forces Europe Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon Other/Not Listed Non-US
Zip Code:
Phone Number of Person Authorized to sign Company/Personal Check:
Amount of Check:
Name of Bank:
Bank City & State:
Name of Person you are enrolling in class:
Class in which you are enrolling:
Email Address of Person Authorized to sign Company/Personal Check:
Routing Number from Bottom of Check:
Account Number from Bottom of Check:
By supplying this information I agree that a paper draft (check) OR an Electronic Draft will be submitted to my checking account for the amount specified: TYPE "YES" TO AGREE: