Questions marked with an asterisk (*) are mandatory.

1	* Register today for 2010 Medicare Advantage and Part D Certification! Please enter your Email address:

2	* For which session would you like to register? Sept. 15 1pm-4pm -- Everett -- 7600 Evergreen Way Sept. 17 9am-noon -- Everett -- 7600 Evergreen Way Sept. 22 1pm-4pm -- Burlington -- 333 Gilkey Road Sept. 22 10am-1pm -- Seattle -- 1800 9th Avenue Sept. 23 9am-noon -- Burlington -- 333 Gilkey Road Sept. 24 10am-1pm -- Tacoma -- 1501 Market Street Sept. 28 8am-noon -- Yakima -- Howard Johnson Plaza - 9 North 9th Street Sept. 29 1pm-4pm -- Seattle  -- 1800 9th Avenue Oct. 1 9:30am-12:30pm -- Port Angeles -- Red Lion - 221 N. Lincoln Oct. 1 1pm-4pm -- Tacoma -- 1501 Market Street Oct. 5 8am-noon -- Walla Walla -- Best Western Walla Walla Suites Inn - 7 East Oak Street Oct. 5 9am-noon -- Everett -- 7600 Evergreen Way Oct. 6 9am-noon -- Centralia -- King Oscars - 1049 Eckerson Road Oct. 6 1pm-4pm -- Kirkland -- Evergreen Hospital Auditorium - 12040 NE 128th Street Oct. 7 9am-noon -- Burlington -- 333 Gilkey Road CLOSED Oct. 13 1pm-4pm -- Burlington -- 333 Gilkey Road CLOSED CLOSED Oct. 21 1pm-4pm -- Everett -- 7600 Evergreen Way Oct. 22 9am-noon -- Everett -- 7600 Evergreen Way CLOSED Oct. 27 1pm-4pm -- Seattle -- 1800  9th Avenue Oct. 29 1pm-4pm -- Tacoma -- 1501 Market Street

3	* First Name:

4	* Last Name:

5	* Agent Number:

6	* WOIC Number:

7	Phone Number: