Request For Continuing Education Certification Form - Measuring School Risks (Wbt)
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1CSRM ONLINE
Request for Continuing Education Certification
Measuring School Risks (WBT)
DATE of EXAM: ________________
/
/
Name (as it appears on your license):
Date of Birth:
(
)
Company Name:
Office Phone :
Email:
Mailing Address:
check one: Home or Office
City / State / Zip:
FILING FEES Credit Card Information:
AmEx
MC
Visa
Discover
Name on Card:________________________________________________________________________________________
Card Number: ________________________________________________________________________________________ Exp. Date _______/_____
State Fees: CE PROCESSING MAY BE DELAYED IF STATE FEES ARE NOT INCLUDED WITH THIS FORM.
A.
Resident State Only: Your home state has a continuing education law and a reciprocal agreement with your non-resident state. You will not
B.
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
THE NATIONAL ALLIANCE ATTN: CONTINUING EDUCATION DEPT PO BOX 27027 AUSTIN TX 78755-2027
request forms and appropriate fee(s) to:
Resident State
Resident State
NPN
NPN
Alabama
Nebraska
State Fee $8
State Fee $8
NPN
License #
Alaska
Nevada
State Fee $8
State Fee $ 8
License #
NPN
Arizona
New Hampshire
Agent State Fee $8
NPN
Arkansas
License #
State Fee $8
New Jersey
License #
License #
California
New Mexico
License #
License #
Colorado
New York
License #
NPN
Connecticut
North Carolina
State Fee $3.75
State Fee $13.20
NPN
NPN
Delaware
North Dakota
State Fee $8
State Fee $8
NPN
NPN
DC
Ohio
State Fee $8
State Fee $8
Agent License #
Agent License #
Florida
Oklahoma
ADJ License #
ADJ License#
License #
NPN#
Georgia
Oregon
Entity #
State Fee $8
Hawaii
License #
License #
Idaho
Pennsylvania
State Fee $5
State Fee $8
NPN#
NPN
Puerto Rico
Illinois
State Fee $8
State Fee $4
NPN
License #
Rhode Island
Indiana
State Fee $8
State Fee $4
License #
License #
South Carolina
Iowa
License #
State Fee $8
South Dakota
NPN #
State Fee $8
Kansas
NPN
State Fee $7
Tennessee
License #
State Fee $8
Kentucky
License #
License #
Texas
Louisiana
License #
State Fee $6
Maine
License #
License #
Utah
Maryland
State Fee $8
State Fee $4.80
License #
License #
Vermont
Massachusetts
State Fee $12
State Fee $1.50
License #
State Fee $8
Virginia
Michigan
OIC #
License #
Washington
Minnesota
NPN #
License #
West Virginia
Mississippi
ADJ License #
State Fee $12
License #
Wisconsin
State Fee $4
License #
NPN
Wyoming
Missouri
State Fee $8
State Fee $8
NPN
Montana
State Fee $8
I understand to receive State CE credit; I must pass a proctored exam and submit this form (and any applicable state fee.)
Your Signature:
Date
WMEA Online Revised 10/10/2014
Check here if you do not need this course filed for CE
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