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

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State of California
Department of Insurance
Prelicensing Continuing Education Program Course Attendance
Record and Verification Form
LIC 446-5 (Rev 10/2012)
Curriculum and Officer Review Bureau - Education Unit
300 Capitol Mall
Sacramento, CA 95814-4309
Information (916) 492-3064
Course Number:
__________________________
Course Title:
______________________________________________________________
______________________________________________________________
Provider Number:
__________________________
Provider Name:
______________________________________________________________
______________________________________________________________
Class Location:
______________________________________________________________
Street
City
State
Zip Code
Class Date(s):
______________________________________
Verification:
I have reviewed and verified that the persons named on the attached Course Attendance Record Sheet(s),
consisting of ______ pages, were present at this class during the times and days indicated.
________________________________________________________________________________
Original Signature of Instructor/(Subject Matter Expert)
Date
________________________________________________________________________________
Printed Name of Instructor/(Subject Matter Expert)
Certification:
I have reviewed this Course Attendance Record Verification and the attached Course Attendance Record
Sheet(s), and certify that I find them accurate and in order, to the best of my knowledge.
►________________________________________________________________________________
Original Signature of Provider Director/Subject Matter Expert
Date
________________________________________________________________________________
Printed Name of Provider Director/Subject Matter Expert

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