23 CAR pt. 18, Appendix D. Application For Instructor Approval

ARKANSAS INSURANCE DEPARTMENT APPENDIX D APPLICATION FOR INSTRUCTOR APPROVAL FOR USE WITH 23 CAR pt. 18 Provider Name: Provider # Phone # Contact Person Instructor Information I. Applicant Name 2. Applicant's Contact Address: Street or P.O. Box 3. Applicant's Phone # ______________ 4. Applicant's e-mail address ________ City, State Applicant's Fax Number Zip Qualifications of Instructor: The applicant can attach a Resume or Curriculum Vitae. 5. Summarize all prior insurance experience which totals 2 or more years. (Attach additional sheets if necessary). If you do not have insurance experience—enter N/A 6. Please summarize insurance education, including but not limited to college or university insurance course hours. Include any professional designations or number of hours obtained toward professional designation. 7. List all current resident and non-resident insurance licenses you currently hold. List the State of issue, License Type and License#. _____________________________________ 8. Have you ever been involved in an administrative proceeding regarding any professional license? __ Yes No If yes attach full detailed statement and copies of official documents. Course of Instruction 9. What type courses of instruction do you propose to serve as instructor? I hereby certify that, under penalty of perjury, all the information submitted in this application and attachments is true and complete. Signature Date Department Use Only Approved by ____________________________________ Date _______________________________ Disapproved by ____________________________________ Date