23 CAR pt. 18, Appendix C. Continuing Education Provider Application

ARKANSAS INSURANCE DEPARTMENT APPENDIX C CONTINUING EDUCATION PROVIDER APPLICATION Name of Provider: Address: Street or P.O. Box City State Zip Phone Number: ___________________________________ Fax # _______________________________ Name of Contact Person #1 __________________________________________________________________ Contact Person Phone # _____________________________________ Fax # __________________________ Contact Person E-mail: Name of Contact Person #2 Contact Person Phone # Contact Person E-mail: What other States are you approved as a Provider of Continuing Education: List Representatives Authorized to Sign Certificates for Provider: Name Title Signature Name Title Signature Name Title Signature Type of Courses Provider Will Offer: (check all that apply) Producer (agent/broker) Title _________ Adjuster Signed _____________________________________ Printed Name _______________________________ Title ______________________________________ Dated *******THIS FORM IS TO BE SUBMITTED WITH A REGISTRATION FEE OF $100******* For Department Use: Fee Received: _________________________________ Check or Route Slip: ____________________________ Approved by __________________________________________ Date: _____________________________ Disapproved by ________________________________________ Date: _____________________________ Page 1 oft 1 Fax #