Florida Association of Insurance Agents

Webinar/Webcast Package Pricing
Instructions:  Please fill in the information requested below.

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Company Information:
*Contact Name:
*Company Name:
Address:
City:
State:	Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska Nevada New Hampshire New Jersey New Mexico New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming
Zip:
*Phone:
Fax:
*E-mail:
How did you hear about our package pricing?	On the Web FMS Rep Other
If FMS Rep, enter name of rep here:
Other:

Number of hours (webcast and/or webinar):

50-99 Hours - $22 per hour 100+ Hours - $19 per hour *Number of hours (webcast and/or webinar):

Credit Card Information:
*Credit Card:	Select One Master Card Visa
*Credit Card No:	---
*V-Code:
*Expiration Date	(mm/yy)
*Credit Card Billing Address:
*City:
State:	Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska Nevada New Hampshire New Jersey New Mexico New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming
*Zip:
* Name on Card:

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