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Request for Continuing Education Certification

Workers Compensation 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.

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

 NPN

Alabama

 NPN

Montana

State Fee $4

 NPN

NPN#

Alaska

Nebraska

State Fee $4

 License #

Arizona

Nevada

 NPN

State Fee $4

Arkansas

 Agent State Fee $4

New Hampshire

NPN #

 ADJ State Fee $4

 Agent State Fee $4

 License #

 Multi Lines ADJ State Fee $4

California

 ADJ License #

 Workers Comp ADJ State Fee $4

 License #

Colorado

New Jersey

 License #

Connecticut

New Mexico

State Fee $3.75

 License #

New York

 NPN

Delaware

 NPN

North Carolina

State Fee $4

State Fee $6.60

 License #

District of Columbia

 NPN

North Dakota

State Fee $4

 Agent License #

Florida

 NPN

Ohio

 ADJ License #

State Fee $4

 License #

Georgia

 Agent License#

Oklahoma

 Entity #

Hawaii

 ADJ License#

 License #

Idaho

NPN#

Oregon

State Fee $4

 NPN

Illinois

 License #

Pennsylvania

 License #

Indiana

State Fee $5.00

State Fee $4

 NPN

Rhode Island

 NPN

Iowa

State Fee $4

 License #

South Carolina

 NPN #

Kansas

 License #

South Dakota

State Fee $4

 License #

Kentucky

 NPN

Tennessee

 License #

Louisiana

State Fee $4

 ADJ License #

 License #

Texas

 License #

Maine

State Fee $3

 License #

Maryland

Utah

State Fee $4

 License #

Massachusetts

 License #

Vermont

State Fee $1.50

State Fee $6

 System ID#

Michigan

 License #

Virginia

State Fee $4

 OIC #

Washington

 License #

Minnesota

 NPN #

West Virginia

Mississippi

License #

State Fee $6

 Agent State Fee $4

 License #

Wisconsin

 ADJ State Fee $4

 License #

Wyoming

 NPN

Missouri

State Fee $4

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

Your Signature

Date

WH6 rev 06.5.2015

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

Form Wh6 - Request For Continuing Education Certification - Workers Compensation Wbt - 2015

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