Form Wrfx - Request For Continuing Education Certification - Risk Financing-Diamond Creek Resorts Wbt - 2013

Request for Continuing Education Certification

Date of Exam______________________

Risk Financing-Diamond Creek Resorts WBT

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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 _______/_____

A.

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:

B.

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.

C.

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

D.

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

Resident State

Alabama

 NPN

Nebraska

 NPN#

State Fee $!0

State Fee $10

Alaska

 NPN

Nevada

 License #

State Fee $10

State Fee $10

Arizona

 License #

New Hampshire

 NPN

Arkansas

 License #

State Fee $10

State Fee $3.00

New Jersey

 License #

California

 License #

New Mexico

 License #

Colorado

 License #

New York

 License #

Connecticut

 License #

North Carolina

 NPN

State Fee $3.75

State Fee $16.50

Delaware

 NPN

North Dakota

 NPN

State Fee $10

State Fee $10

DC

 NPN

Ohio

 NPN#

State Fee $10

State Fee $10

Georgia

 License #

Oklahoma

 Agent License #

Hawaii

 Entity #

Oregon

NPN#

Idaho

 License #

State Fee $10

State Fee $10

Pennsylvania

 License #

Illinois

 NPN State Fee $5.00

State Fee $5.00

Indiana

 License #

Puerto Rico

NPN#

State Fee $4

State Fee $10

Iowa

 NPN

Rhode Island

 NPN

State Fee $10

State Fee $10

Kansas

 NPN

South Carolina

 License #

State Fee $10

Kentucky

 License #

South Dakota

 License #

Louisiana

 License #

State Fee $10

Maine

 License #

Tennessee

 NPN

Maryland

 License #

State Fee $10

State Fee $6

Texas

 License #

Massachusetts

 License #

State Fee $7.50

State Fee $5

Utah

 License #

Michigan

 System ID#

State Fee $9

State Fee $10

Vermont

 License #

Minnesota

 License #

State Fee $15

Mississippi

 License #

Washington

 OIC #

State Fee $4

Missouri

 NPN

Virginia

 License #

State Fee $10

West Virginia

 NPN #

Montana

 NPN

State Fee $15

State Fee $10

Wisconsin

 License #

Wyoming

 License #

State Fee $9

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

___________________________________________________________

___________________________________

Date

WRFX Online 12/23/2013

Your Signature

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