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Insurance Institute of Manitoba

SPECIAL SEMINAR PRESENTATION

REGISTRATION FORM

Essential Skills for the Broker and Agent

Deadline: March 15, 2011

CONTACT PERSON: ______________________________________ MEMBER #: _____________ COMPANY: ___________________________________________________________________ ADDRESS: _____________________________________________________________________ CITY/TOWN: _____________________________ PROVINCE: ________ POST CODE: ________ DAYTIME PHONE: (204) _________________________________________________________ E-MAIL (for confirmation of registration): ____________________________________________

METHOD OF PAYMENT:

Payment must be received at the time of registration to secure your spot.

Amount enclosed: $ ______________

  • Personal Cheque attached

  • Company Cheque attached | Cheques payable to: The Insurance Institute of Manitoba

  • Credit Card details below

  • Visa

  • MasterCard

Card number: _____________________________________ Cardholder name: _________________________________ Cardholder signature: ______________________________

Expiry Date:

/

____ _____

RETURN THIS FORM AND PAYMENT TO:

Insurance Institute of Manitoba 303-175 Hargrave Street, Winnipeg, MB R3C 3R8 (we’ve moved) Phone: 204-956-1702 | Fax: 204-956-0758 | E-mail: IIMmail@insuranceinstitute.ca

FOR OFFICE USE ONLY:

  • Taken

  • Shipped

Cash Control Batch#

_______

Order#

____________

Ticket#

__________

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