CLASS REGISTRATION FORM
CLASS LOCATION___________________________________________ CLASS DATE________________________________
ATTENDEE NAME____________________________________________ PHONE #____________________________________
ATTENDEE ADDRESS_________________________________________ CITY_______________ ZIPCODE______________
NAME ON LICENSE___________________________________________ TDHCA LICENSE #____________________________
RETAILER/BROKER/COMPANY NAME___________________________________________________________________________
RETAILER/BROKER LIC #_____________________________________________________________________________________
BUSINESS LOCATION ADDRESS_______________________________ CITY_______________ ZIPCODE______________
ATTENDEE EMAIL ADDRESS__________________________________________________________________________________

MAIL THIS WITH $80  CHECK OR MONEY ORDER TO:     TXMHS     P.O. BOX 422     BEDFORD, TX 76095