State Form 39287 - Verification Of Agent Training

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INDIANA COMMISSION ON
VERIFICATION OF AGENT TRAINING
PROPRIETARY EDUCATION
State Form 39287 (R6 / 3-09)
Name of applicant agent
Name and location of institution
Date submitted (month, day, year)
TYPE OF TRAINING RECEIVED BY THE APPLICANT AGENT:
1. Classroom?
Yes
No
(a) Give number of hours of classroom training:
2. Field training?
Yes
No
(a) Give number of hours field training:
(b) Name of individual who supervised training:
(c) Give explicit description of the field training:
3. Indiana Code 21-17 and Rules and Regulations?
Yes
No
(a) Number of hours in training:
4. Course content?
Yes
No
(a) Number of hours in training on course content:
5. Total hours of training received prior to submission of this form:
I hereby swear or affirm that the information supplied on this form is true.
Signature of applicant
Date (month, day, year)
STATE OF _______________________________
SS:
COUNTY OF _____________________________
Subscribed and sworn to before me this ________ day of _____________________________________________ , ____________.
Printed name of notary public
Signature of notary public
County of residence
Date commission expires (month, day, year)
The undersigned hereby certifies that the applicant agent has been thoroughly trained and understands Indiana Code 21-17, the Rules and Regulations of
the Indiana Commission on Proprietary Education and the correct appeal procedures in the event of agent license suspension. (Reference 570 IAC 1-5-4).
Signature of training supervisor
Date (month, day, year)
Printed name of training supervisor
Official capacity
STATE OF _______________________________
SS:
COUNTY OF _____________________________
Subscribed and sworn to before me this ________ day of _____________________________________________ , ____________.
Printed name of notary public
Signature of notary public
County of residence
Date commission expires (month, day, year)

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