23 CAR pt. 18, Appendix E. Individual Certificate of Completion

APPENDIX E INDIVIDUAL CERTIFICATE OF COMPLETION FOR USE WITH 23 CAR pt. 18 Producer Name (Type or Print) Arkansas License Number(s) Street Address City State Zip Code Authorized Representative (Type or Print) of Course Provider do hereby certify that the person named herein has successfully completed the following approved courses: Course Title __________________________________________________________ Number of Credit Hours Earned _________________ Course Number ____________ Date of Course Completion ______________________________________________ This course has been approved by the Arkansas Department of Insurance pursuant to Rule 50. Date Signature of Authorized Representative Date Signature of Producer THIS FORM MAY BE PROVIDED TO THE PRODUCER UPON COMPLETION OF THE COURSE IF REQUESTED BY THE PRODUCER.