Regal School of Real Estate 3131 Flightline Drive, Suite 304
Lakeland, FL 33811
Phone: (863) 644-6464 Fax: (863) 869-8600
Registration Form
Name:_______________________________________ Date: _________
Address:____________________________________________________
Home Phone : __________________ Cell Phone: ___________________
E-mail Address: ___________________ Fax Number: ________________
Social Security Number: ____________________ Date of Birth: _________
Please Initial That You Have Read and Agree To Our Policies _______
Method of Payment: Visa MasterCard Check Money Order
Credit Card Number: ________________________________ Expires: _________
Authorized Signature: _______________________________ Amount: $_________
Please Reserve My Seat for the Following Course:
______________________________________________________________
Start Date: _______ Real Estate License Number: ______________ Expires: ______
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