On-Line Registration

First Name

Middle Initial

Last Name

Last 4 of SSN (optional)

Or Register Your Company

Student Primary Phone Number (required)

Alternate Phone Number

Student Email

Student Mailing Address

City

State

Zip Code

PAYMENT METHOD

Please check all that apply
Check - Payable to Advanced Minnesota
Credit Card - Please call with Credit Card information
Purchase Order or Letter of Billing Authorization

Please fax: 218-749-7782
or mail to: Advanced Minnesota
1515 East 25th Street
Hibbin, MN 55746

THIRD PARTY BILLING INFORMATION

If you are paying via Purchase Order or Letter of Billing Authorization, please enter the third-party billing information below.

Billing Contact Name

Billing Mailing Address

City

State

Or Province

Zip Code

Billing Contact Phone Number

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