Please use this page to order multiple enrollments in our COBRA Training & Certification Program.
To pay by check, simply fill out the information below and submit this page with payment to the address at the bottom of this form. Please call 678-366-3959 to pay for multiple enrollments using Visa or MasterCard.
Account
Information: Primary Contact
Please provide information for the key contact person, including company name and address.*
= required fields
First Name*:
Last Name*:
Company Name*:
Address 1*:
Address 2:
City*
State*
Zip*:
Phone*:
Ext:
Fax:
E-Mail Address*:
I
am: (please select
all that apply)
An Employer
An Agent
An Insurer
A TPA
Other
Select
Your User Name and Password
Please provide
a user name and password to access the subscriber areas. You may
change this anytime by using the "My Account" function found on the menu bar.
User Name*:
Password*:
Additional Users
Please provide information for the additional individuals who are enrolling in the Program. If additional space is needed, please print this form and hand fill the blanks or write the information on the back page.
Note: Each individual will be given a separate account and can change his or her user name or password at any time online by using the "My Account" function found on the menu bar.
2nd Person
First Name*:
Last Name*:
Phone*:
Ext:
E-Mail Address*:
User Name*:
Password*:
3rd Person
First Name*:
Last Name*:
Phone*:
Ext:
E-Mail Address*:
User Name*:
Password*:
4th Person
First Name*:
Last Name*:
Phone*:
Ext:
E-Mail Address*:
User Name*:
Password*:
5th Person
First Name*:
Last Name*:
Phone*:
Ext:
E-Mail Address*:
User Name*:
Password*:
Select Your Discount Pricing Level
The COBRA Training Program has two levels: Stand-Alone or bundled with Ongoing Support Services.
