Securities Series 6 & 63 Class Registration Form

Registration for the Securities Class includes the following:

This class is taught by : Jeff Tharp
1.) Series 6 & 63 Student Package (Book & Study Software)
2.) Classroom Study Booklet We recommend that you submit you U-4 prior to class, or studies
3.) Publisher's Technical Support (We use Exam Simulator material in class, these are also available
in spanish, call for more information)
4.) Post Class Instructor Accountability Program
5.) A Re-Test Guarantee (See Details)
PRINT, FILLOUT, AND FAX THIS PAGE ONLY
Note: The FIRST FIVE Students Registered & Paid get a FREE Terminology CD (Valued at $5.00)
CLASS INFORMATION
LOCATION DATES & TIMES
Norman Mitchell's Office September 25 & 26th, 2009
Address 455 E. Central Expressway Friday: 6:00pm - 10:30pm
Suite 106 Saturday : 12:00 noon - 9:30 PM
Harker Heights, TX 76548 Class Code 092509HSTX
STUDENT INFORMATION
NAME Solution Number
Address Social Security #
City State Zip
Home # Cell #
Go Solo # Email
Have you submitted U-4 Application? (Yes/No) Date Submitted
RVP Name Phone # Fax #
PAYMENT INFORMATION
Classroom Amount with Book & Software (in class) $189 $
OR: To get material sooner, Add $15.00 for UPS Overnight $
(OR) Classroom Only (warning, we teach directly for the ABLE PASS Material $139 $
**Late registrations fee of $20.00 if paid after Sept 16, 2009, or in class **$20 $
Shipped Separate Securities 6,63 & 26 Terminology Audio CD $60 $
TOTAL AMOUNT $
Credit Card # - - - Today's Date
Experation Date / 3 Digit Secuity # Accepted Methods of Payment
Name as it appears on card Visa
Card Holder's Signature Mastercard
By signing, I authorize Jeff Tharp to Cashiers Check/Money Order
charge my account the amount above Cash at the door
Note: Once paid, there is a $5.00 Cancellation Charge, if you can't attend class, call for details.
Note: When you receive your credit card statement, it will show jefftharp.com as the Mercant. If you dispute a valid charge without calling
us first, there will be an additional $25 fee charged to your account for the processing charges associated with a dispute. If you call,
the $25 may be waived, but $5 may still apply. So, PLEASE CALL FIRST, 210-325-6302 or 877-680-5869
WE DO NOT ACCEPT PERSONAL CHECKS!
Fax this registration form to 877-680-5869 and press "Start" or "Send" immediatley
*When paying by Money Order, allow an extra 4 days mailing time for Registration Form. If there is not sufficient
time to mail registration with money order, **Add a $20 late registration fee for "Pay in Class" and Fax it in.
 QUALIFICATIONS CLASS INCLUDES
1.) Must have U-4 Submitted By Class 1.) Series 6 & 63 Book PLUS Exam Simulator
2.) DSL or Faster Internet Connection 2.) Instructor Tutoring after Class
3.) Microphone, If You Want To Ask Questions Live
3.) ReTest Guarntee
4.) May Sit Through Class Again for FREE Within 120 Days
Book Shipped xx/xx/09

Securities Series 6 & 63 Live Online Class Form

NAME SOLUTION #

ADDRESS Social Security #

DAY PHONE RVP NAME

CELL PHONE GO SOLO #

EMAIL ADDRESS

QUESTIONS? CALL JEFF THARP 210-325-6302

DATES AND TIMES
Tuesday Sept 15 - Noon - 4:00 PST
Wednesday Sept 16 - Noon - 4:00 PST Mail To: jefftharp.com 5090 Sring Branch Rd, Spring Branch, TX 78070
Thursday Sept 17 - Noon - 4:00 PST
Credit Card #
Experation Date
Name as it appears on card
Card Holder's Signature
By signing, I authorize Jeff Tharp to
COST AND PAYMENT PROCEDURES
Price - $150 Visa, MC, or Money Order
Please mail form no later than Sept 1, so that we have time to get
your book and software to you before class!!
Today's Date
/ 3 Digit Secuity # Accepted Methods of Payment
Visa Visa
Mastercard
Cashiers Check/Money Order

charge my account the amount above

Note: Once paid, there is a $5.00 Cancellation Charge, if you can't attend class, call for details.
Note: When you receive your credit card statement, it will show jefftharp.com as the Mercant. If you dispute a valid charge without
calling us first, there will be an additional $25 fee charged to your account for the processing charges associated with a dispute.
If you callthe $25 may be waived, but $5 may still apply. So, PLEASE CALL FIRST, 210-325-6302 or 877-680-5869
WE DO NOT ACCEPT PERSONAL CHECKS!

STUDENT INFORMATION
CIRCLE ONE
1.) Have you submitted your U-4? (Y/N) When?
2.) Is your test window open? (Y/N)
3.) Have you tested before? (Y/N)
4.) Product Code from book (OFFICE ONLY)
Credit Card # Today's Date
Experation Date / 3 Digit Secuity # Accepted Methods of Payment
Name as it appears on card Visa Visa
Card Holder's Signature Mastercard
By signing, I authorize Jeff Tharp to Cashiers Check/Money Order
charge my account the amount above
Note: Once paid, there is a $5.00 Cancellation Charge, if you can't attend class, call for details.
Note: When you receive your credit card statement, it will show jefftharp.com as the Mercant. If you dispute a valid charge without
calling us first, there will be an additional $25 fee charged to your account for the processing charges associated with a dispute.
If you callthe $25 may be waived, but $5 may still apply. So, PLEASE CALL FIRST, 210-325-6302 or 877-680-5869
WE DO NOT ACCEPT PERSONAL CHECKS!
d Methods of Payment
Visa
Mastercard
ers Check/Money Order

valid charge without

ciated with a dispute.
877-680-5869