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Request for Continuing Education Certification

Employment Practices Liability 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 _______/_____

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

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.

Late Fee: Turn in this completed form with your affidavit within 5 days to avoid the $20.00 late fee.

Rush Fees: A $25 fee is required for rush processing. An additional $15 fee is required for overnight service.

Checks for all fees are 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

 NPN

Alabama

Montana

 State Fee $4

State Fee $4

 NPN

NPN#

Alaska

Nebraska

State Fee $4

 License #

Nevada

Arizona

 NPN

State Fee $4

Arkansas

 Agent State Fee $4

New Hampshire

NPN #

 ADJ State Fee $4

 Agent State Fee $4

 Multi Lines ADJ State Fee $4

 License #

California

 License #

 ADJ License #

New Jersey

 License #

Colorado

New Mexico

 License #

Connecticut

New York

 NPN

State Fee $3.75

North Carolina

 NPN

Delaware

State Fee $6.60

 NPN

State Fee $4

North Dakota

 License #

District of Columbia

State Fee $4

 NPN

State Fee $4

Ohio

 Agent License #

Florida

State Fee $4

 ADJ License #

 Agent License#

Oklahoma

 License #

 ADJ License#

Georgia

 Entity #

NPN#

Hawaii

Oregon

 License #

Idaho

State Fee $4

 License #

State Fee $4

Pennsylvania

 NPN

State Fee $5.00

Illinois

 License #

 NPN

Indiana

Rhode Island

State Fee $4

 License #

 NPN

South Carolina

Iowa

 License #

State Fee $4

South Dakota

 NPN #

State Fee $4

Kansas

 NPN

State Fee $4

Tennessee

 License #

State Fee $4

Kentucky

 License #

Texas

Louisiana

 ADJ License #

State Fee $3

 License #

Maine

Utah

 License #

State Fee $4

Maryland

 License #

State Fee $4

Vermont

 License #

State Fee $6

Massachusetts

 License #

Virginia

State Fee $1.50

 System ID#

 OIC #

Washington

Michigan

 NPN #

State Fee $4

West Virginia

 License #

State Fee $6

Minnesota

 ADJ License #

 License #

Wisconsin

 License #

Mississippi

Wyoming

 Agent State Fee $4

State Fee $4

 ADJ State Fee $4

 NPN

Missouri

State Fee $4

I understand to receive State CE credit; I must pass the proctor exam and submit this CE form along with any applicable state fees.

Your Signature

Date WH7 Online rev 06.5.2015

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

Form Wh7 - Request For Continuing Education Certification - Employment Practices Liability Wbt - 2015

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