Prelicensing Continuing Education Program Course Attendance Record And Verification Form With Record Sheet Page 2

Download a blank fillable Prelicensing Continuing Education Program Course Attendance Record And Verification Form With Record Sheet in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Prelicensing Continuing Education Program Course Attendance Record And Verification Form With Record Sheet with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

Course Attendance Record Sheet

Provider #:

Provider Name:

Page

Course #:

Course Name:

Date:

Begin Time:

End Time:

Session

Instructor/Subject Matter Expert:

Location:

Street

City

State

Zip

Note: Those students who do not sign in and out will not be granted prelicensing or continuing education credit.

Time-in

Printed Name

Social Security

Individual

Time-out

Signature

(Last, First M.I.)

Number*

Insurance

I certify under penalty of perjury that

AM/PM

License #

AM/PM

these are my correct attendance times.

(Last 4 digits only)

(Attach additional sheets if necessary)

*The Provider is required by the Department pursuant to Insurance Code Sections 1749, 1749.2, 1749.3, 1749.31, 1749.4, 1749.5, 1749.7, 1810.7 and CCR, Title 10, Chapter 5, Sections

2105.7(c)(1), 2105.10(b)(1), and 2188.5 to collect and maintain a unique student identifier that will properly identify students while protecting the confidentiality and privacy of this non-

public personal information. The last four digits of the social security number or the individual insurance license number will allow the Department to assign credit to students who

have completed prelicensing or continuing education courses.