Form Wrmex - Request For Continuing Education Certification - Fundamentals Of Risk Management - Diamond Creek Resorts Wbt - 2013

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Request for Continuing Education Certification
Date of Exam___________________
Fundamentals of RM-Diamond Creek Resorts WBT
/
/
Name (as it appears on your license):
Date of Birth:
(
)
Company Name:
Office Phone :
Email:
 Office
Mailing Address:
check one:
 Home
City / State / Zip:
FILING FEES Credit Card Information
AmEx 
MC 
Visa 
Discover 
Name on Card________________________________________________________________________________________
Card Number: ________________________________________________________________________________________ Exp. Date _______/_____
A.
State Fees: CE PROCESSING MAY BE DELAYED IF STATE FEES ARE NOT INCLUDED WITH THIS FORM.
Check here if a check will be mailed for state fees
B.
Resident State Only: Your home state has a continuing education law and a reciprocal agreement with your non-resident state. You will not be
issued additional certificates. Please contact the Licensing Dept. in your non-resident state(s) to determine the documentation required to renew
your non-resident license.
C.
Late Fee: Turn in this completed form with your affidavit within 5 days to avoid the $20.00 late fee.
D.
Rush Fees: A $25 fee is required for rush processing. An additional $15 fee is required for overnight service.
Make checks for all fees (state, late, rush, and/or overnight) payable to: The National Alliance. Submit payment with this form. Please mail late request forms and appropriate fee(s) to:
THE NATIONAL ALLIANCE  ATTN: CONTINUING EDUCATION DEPT  PO BOX 27027  AUSTIN TX 78755-2027
Resident State
Resident State
Alabama
 NPN
Nevada
 License #
State Fee $10
State Fee $10
Alaska
 NPN
State Fee $10
New Hampshire
 NPN
State Fee $10
Arizona
 License #
Arkansas
 License #
New Jersey
 License #
State Fee $3.00
New Mexico
California
 License #
 License #
New York
 License #
Colorado
 License #
Connecticut
 License #
North Carolina
 NPN
State Fee $16.50
State Fee $3.75
Delaware
 NPN
North Dakota
 NPN
State Fee $10
State Fee $10
DC
 NPN
Ohio
 NPN#
State Fee $10
State Fee $10
Oklahoma
License
Georgia
 License #
 Agent
#
Hawaii
 Entity #
Oregon
NPN#
Idaho
 License #
State Fee $10
State Fee $10
Pennsylvania
 License #
Illinois
 NPN
State Fee $5.00
State Fee $5.00
Puerto Rico
NPN#
State Fee $10
Indiana
 License #
Rhode Island
 NPN
State Fee $4
State Fee $10
Iowa
 NPN
South Carolina
 License #
State Fee $10
Kansas
 NPN
South Dakota
 License #
State Fee $10
State Fee $10
Kentucky
 License #
Tennessee
 NPN
Louisiana
 License #
State Fee $10
Maine
 License #
Texas
 License #
Maryland
 License #
State Fee $7.5
State Fee $6
Utah
 License #
Massachusetts
 License #
State Fee $10
State Fee $5
Vermont
 License #
Michigan
 System ID#
State Fee $15
State Fee $10
Virginia
 License #
Minnesota
 License #
Mississippi
 License #
Washington
 OIC #
State Fee $4
Missouri
 NPN
West Virginia
 NPN #
State Fee $10
State Fee $15
Montana
 NPN
Wisconsin
 License #
State Fee $10
Wyoming
 License #
Nebraska
 NPN
State Fee $10
State Fee $10
I understand to receive State CE credit; I must pass the proctor exam and submit this form (along with any applicable state fees.
Your Signature
WRMEX Online 12/23/2013
Check here if you do not need this course filed for CE.

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