To register for multiple locations: Go to registration form    To register by mail or fax for this location ONLY, follow these steps: 1. Print this page. 2. Check desired classes. 3. Fill in required information and send to: Wise Education, Inc. 1501 Cobblestone Ct. Thorofare, NJ 08086 Fax: 856-384-8414   Tuition Total $________  # of   Credits______________   PAYMENT OPTIONS: ____Check #_________ Check amt. $__________   ____Visa    ____MC    ____Discover   Expiration Date _____/______(Required)   CC #_____________________________________    Cardholder Name____________________________                                              (Please print) Signature___________________________________    Comments:_________________________________   __________________________________________

FIRST_______________________MI____   LAST____________________________Jr / Sr / III   DATE OF BIRTH   _  _  / _  _ /  _  _   NJ LIC REF # _  _   _  _   _  _  _ -IP   NJ INS LIC EXP DATE  _  _  /  _  _  /  _  _   HOME PHONE  (  _  _  _  ) _  _  _  -  _  _  _  _   MOBILE PHONE  (  _  _  _  ) _  _  _  -  _  _  _  _   HOME ADDRESS__________________________   CITY/ST______________________ZIP_________   BUS FIRM________________________________   BUS PHONE  (  _  _  _  ) _  _  _  -  _  _  _  _   BUS FAX  (  _  _  _  ) _  _  _  -  _  _  _  _   BUS ADDRESS___________________________   CITY/ST______________________ZIP_________   E-MAIL___________________________________    Please make a copy of this form and mark your calendar. No CE confirmations mailed. PLEASE ATTACH MEMO AS TO ANY SPECIAL NEEDS