NOTE: If you are enrolling in an in-class course, please register with your local Institute or Chapter.
 
 Contact Information
 Title: Telephone:
 Last Name: Fax:
 First Name: E-mail:
 Middle Name:    
 Employer:
 Bus. Address 1: Bus. Province:
 Bus. Address 2: Bus. Postal:
 Business City:    
 
 Shipping Information (if different than address provided above)
 Address 1: Province:
 Address 2: Postal Code:
 City:  
 
 Registration Information
 Upon receipt of this registration form, you will receive:
 
  - Texts (LLQP Part A and Part B)
  - Tuition information
  - Password for on-line tutorial
  - Certification Examination Application - (For A&S only, you receive
    a text and certification exam application.)

Upon successful completion of the Certification Exam, you will receive a Certificate of Completion that allows you to challenge the Regulator's Licensing Exam.
 
 Fee Calculation
 Select an LLQP version:  
 You have selected a province where applies.
 LLQP Reg. Fee:   $ + $ (Shipping) + $ (Tax)  = $
 
 Payment Information
 Credit Card:      

By mail
ONLY:
 Card number:
 Expiry date:  
 Amount:

$

 (Includes GST or HST)


  Signature ________________________________________ (required only if form is printed)
 
  18 King Street East, 6th Floor
Toronto, ON  M5C 1C4
Phone: (416) 362-8586
Fax: (416) 362-2692
E-mail: iicmail@insuranceinstitute.ca

  For applications by MAIL, fill out the form and click PRINT
  For applications by FAX, fill out the form, PRINT and then fax to (416) 362-2692.