Fillable State Form 39287 - Verification Of Agent Training printable pdf download

State Form 39287 - Verification Of Agent Training

Download a blank fillable State Form 39287 - Verification Of Agent Training 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 State Form 39287 - Verification Of Agent Training 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.

Reset Form

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

(a) Give number of hours of classroom training:

2. Field training?

Yes

(a) Give number of hours field training:

(b) Name of individual who supervised training:

3. Indiana Code 21-17 and Rules and Regulations?

Yes

(a) Number of hours in training:

4. Course content?

Yes

(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