PHOTO I.D Contractors Continuing Education, Inc.

Authorized DBPR Provider #0004963

Pictures will be taken in class

I.D. BADGE ENROLLMENT ORDER FORM

I. Employee Name: (as it appears on Soc. Sec. Card) _________________________________________________________________ II. Soc. Sec. # (required for certification processing) XXX-XX ______________ (Last 4 Numbers Only) III. Company Name: _______________________________________________________________ IV. Name of Qualifier: (required) ________________________________________________ FL State License# E___________
Qualifier/ License holder Signature Box (please sign within the box)

V.

Company Address_____________________________________________________________ City _______________________________________________________ State ___ Zip______ VI .Phone ( ) __________________ Fax ( )_____________ E-Mail___________________ VII. Employee Signature Box (please sign within the box)

VIII.

CHECK BOXES THAT APPLY: FASA badge will show a two-year window from date of Initial Certification.
_____ 14 Hours Complete Course $175.00 _____ 6 Hours Re-Cert Course $75.00**

Finger Printing & Background Checks only available for Groups of 10 or more. $75.00 Each Agent

BASA badge will show a two-year window from date of Initial Certification.
_____ 14 Hours Complete Course $175.00 6 Hours Re-Cert Course $75.00**
Finger Printing & Background Checks only available for Groups od 10 or more.$75.00 Each Agent

** Must proof that course was taken within two years. (ID card)
NOTE: It is the employers responsibility to insure their personnel have met the requirements of all Florida Statutes. And F.S. 489 part . School, Inc CPS A.K.A: Contractors Prep CEST AKA: Contractors Exam School of Tampa, Inc
2. The employer and employee will hold CPS & CEST harmless for any misrepresentation, false statements, omissions, errors or incomplete actions either on the part of the company or the employee.

IX.

Method of Payment: (Total must be paid in full at the stated rate upon application.) ___Check Enclosed ___VISA ___Master Card ___American Express Card# _____________________________________ Expiration ___________Sec. Code ____________ Name on Card ______________________________ Signature _________________________________
RETURN COMPLETED FORM WITH , CHECK and/or CREDIT CARD AUTHORIZATION TO:
(Note: We do not accept purchase order numbers. All items must be pre-paid.) (rev: 08-08-2013 )

Contractors Continuing Education, Inc.

1741 N. State Road, 7. Margate FL, 33063
Contact Information: Broward: (954) 971-5383

Dade: (305) 707-8895 W.PB: (561) 247-2245

Tampa: (813) 684-1161

Fax: (954) 971-5385

E-mail: ContractorsPrepSchool@gmail.com Web: ContractorsPrepSchool.com