Request For Continuing Education Certification Form - Agency Operations Wbt

Request for Continuing Education Certification

Agency Operations WBT

DATE of EXAM: ________________

/

/

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

 NPN

 NPN

Alabama

Montana

 State Fee $7

State Fee $8

 NPN

 NPN

Alaska

Nebraska

 State Fee $8

State Fee $4

 License #

 License #

Nevada

Arizona

State Fee $8

 NPN

Arkansas

 NPN

New Hampshire

State Fee $8

 Agent State Fee $7.50

 License #

California

 Public ADJ State Fee $8

 License #

Colorado

 Multi ADJ State Fee $8

 License #

Connecticut

 Workers ADJ State Fee $8

 PC or  LH

 License #

New Jersey

State Fee $3.75

 License #

New Mexico

 NPN

Delaware

 License #

New York

State Fee $8

 NPN

North Carolina

 NPN

DC

State Fee $11.55

State Fee $8

 NPN

North Dakota

 Agent License #

Florida

 ADJ License#

State Fee $8

 NPN#

Ohio

 License #

Georgia

State Fee $7

 Entity #

Hawaii

 Agent License#

 PC or  LH

Oklahoma

 NPN

Oregon

 License #

Idaho

 State Fee $8

State Fee $8

 License #

Pennsylvania

 NPN State Fee $3.50

Illinois

State Fee $5.00

 License #

Indiana

 NPN

Puerto Rico

State Fee $4

State Fee $8

 NPN

Iowa

 NPN

Rhode Island

State Fee $7

State Fee $8

 NPN

Kansas

 License #

South Carolina

State Fee $8

 PC or  LH

 License

Kentucky

 License #

South Dakota

 Agent License #

Louisiana

State Fee $7

 License #

Maine

 NPN

Tennessee

 License #

Maryland

State Fee $7

State Fee $7

 License #

Texas

 License #

Massachusetts

State Fee $6

State Fee $4

 License #

Utah

 System ID#

Michigan

State Fee $8

State Fee $8

 License #

Vermont

 License #

Minnesota

State Fee $10.50

 License #

Mississippi

 License #

Virginia

State Fee $3.50

 OIC #

 NPN

Washington

Missouri

 NPN #

West Virginia

State Fee $7

State Fee $10.50

 License #

Wisconsin

 License #

Wyoming

State Fee $7

I understand to receive State CE credit; I must pass a proctored exam and submit this form (along with any applicable state fees).

__________________________________________________________

___________________________________

Date

Your Signature

AO Online rev 06.5.2015

Check here if you do not need this course filed for CE.