Application for Entitlement

Application for Subsequent Endorsement Entitlement
Please complete this form in its entirety.
Educator's Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
UIC Email Address*
Alternate Email Address
IEIN (from ELIS)*
UIN*
Phone Number*

Area CodePhone Number