Form Wrmex - Request For Continuing Education Certification - Fundamentals Of Risk Management - Diamond Creek Resorts Wbt - 2013

Request for Continuing Education Certification

Date of Exam___________________

Fundamentals of RM-Diamond Creek Resorts WBT

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Name (as it appears on your license):

Date of Birth:

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Company Name:

Office Phone :

Email:

 Office

Mailing Address:

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City / State / Zip:

FILING FEES Credit Card Information

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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

B.

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.

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

Nevada

 License #

State Fee $10

State Fee $10

Alaska

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State Fee $10

New Hampshire

 NPN

State Fee $10

Arizona

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Arkansas

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New Jersey

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State Fee $3.00

New Mexico

California

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New York

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Colorado

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Connecticut

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North Carolina

 NPN

State Fee $16.50

State Fee $3.75

Delaware

 NPN

North Dakota

 NPN

State Fee $10

State Fee $10

DC

 NPN

Ohio

 NPN#

State Fee $10

State Fee $10

Oklahoma

License

Georgia

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Hawaii

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Oregon

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Idaho

 License #

State Fee $10

State Fee $10

Pennsylvania

 License #

Illinois

 NPN

State Fee $5.00

State Fee $5.00

Puerto Rico

NPN#

State Fee $10

Indiana

 License #

Rhode Island

 NPN

State Fee $4

State Fee $10

Iowa

 NPN

South Carolina

 License #

State Fee $10

Kansas

 NPN

South Dakota

 License #

State Fee $10

State Fee $10

Kentucky

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Tennessee

 NPN

Louisiana

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State Fee $10

Maine

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Texas

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Maryland

 License #

State Fee $7.5

State Fee $6

Utah

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Massachusetts

 License #

State Fee $10

State Fee $5

Vermont

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Michigan

 System ID#

State Fee $15

State Fee $10

Virginia

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Minnesota

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Mississippi

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Washington

 OIC #

State Fee $4

Missouri

 NPN

West Virginia

 NPN #

State Fee $10

State Fee $15

Montana

 NPN

Wisconsin

 License #

State Fee $10

Wyoming

 License #

Nebraska

 NPN

State Fee $10

State Fee $10

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

Your Signature

WRMEX Online 12/23/2013

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