Course Attendance Record Sheet

COURSE ATTENDANCE RECORD SHEET

Independent Insurance Agents of West Virginia

Webinar

This form has been given to you at the beginning of this seminar. In order to receive CE credits, you must complete this form. You will be ineligible for CE credits if this form is not returned at the end of the seminar. There are NO exceptions.

Course Title: ______Course Date: ______

Course Time: ______

Time In Signature Time Out Signature

Name (as it appears on license): ______

Are you replacing someone? If so, provide her/his name: ______

Agency/Brokerage/Company: ______

Business Address: ______

City: ______State: ______Zip Code:______

Phone Number: ______Fax Number: ______

License Number: ______Resident State License Number: ______

E-Mail: ______

I certified under penalty of perjury that these are correct times for my attendance at these sessions.

Signature: ______Date: ______

In order to comply with the West Virginia Offices of the Insurance Commissioner’s regulation on timely notification, you must return the course attendance records no later than five business days after the class date. Late receipt of course attendance records will result in no CE credit being applied to license renewals by the West Virginia Offices of the Insurance Commissioner.

Please return via fax at 304.343.5810 or e-mail to Amanda Runyon at [email protected]. IIAWV WEBINAR GROUP CE RETURN COVER SHEET AND MONITOR VERIFICATION

Course Title: ______

Course Date: ______

Brokerage/Agency Name: ______

City: ______State: ______Zip Code: ______

Phone Number: ______Fax Number: ______

E-Mail: ______

List name(s) (as it appears on license):

Name License Number

1. ______

2. ______

3. ______

4. ______

5. ______

6. ______

7. ______

8. ______

9. ______

10. ______

Monitor Verification - Please Note: CE credits cannot be issued without this section being completed.

Administered from: ______a.m. /p.m. to ______a.m./p.m. (please circle)

I certify that the agent(s) name listed above has/have completed the webinar session. I have administered this webinar and therefore, verify that at no time did any fraudulent behavior and/or use of this webinar occur which could result in loss or suspension of the broker/agent’s license or this firm’s license.

Signature: ______Date: ______Please return via fax at 304.343.5810 or e-mail to Amanda Runyon at [email protected].