760 IAC 1-6.2-14 Certificate of completion

Sec. 14. (a) The certificate of completion for a prelicensing class required by section 11 of this rule is as follows: CERTIFICATE OF COMPLETION PRELICENSING BAIL BOND OR RECOVERY AGENT LICENSE This Certificate must be presented at the examination site and must be accompanied by two (2) forms of identification, one of which must include a photograph. This Certificate is valid for six (6) months after the date issued. ___________________________ _______________________________ Name of Student Date of Birth ___________________________ _______________________________ Name of School Address of School ___________________________ _______________________________ Name of Instructor City/State Zip Code Days of Week Class Offered (circle): M T W TH F S S Date and Time of Class: ________________________________________________ Total number of hours of class instruction received by applicant at the above location and time and in the presence of the above instructor(s) ______________ I hereby certify, under penalty of perjury, that the above information is true and correct to the best of my knowledge and belief and I understand that a false statement is cause for denial, suspension, or revocation of a class approval. ___________________________ ______________________________ Date Instructor's Name (print) ______________________________ Instructor's Signature I hereby certify, under penalty of perjury, that the above information is true and correct to the best of my knowledge and belief, and I understand that a false statement is cause for denial, suspension, or revocation of a bail bond license. ______________________ ______________________________ Date Applicant's Name ______________________________ Applicant's Signature (b) The certificate of completion for a continuing education class required by section 11 of this rule is as follows: CERTIFICATE OF COMPLETION CONTINUING EDUCATION BAIL BOND OR RECOVERY AGENT LICENSE This Certificate shall be submitted to the Department of Insurance along with the renewal application. _____________________________ ___________________________________________________ Name of Student Date of Birth _____________________________ ___________________________________________________ Name of School Address of School _____________________________ ___________________________________________________ Name of Instructor Days of Week Class Offered (circle): M T W TH F S S Date and Time of Class: ____________________________________________ Total number of hours of class instruction received by applicant at the above location and time and in the presence of the above instructor(s): __________ I hereby certify, under penalty of perjury, that the above information is true and correct to the best of my knowledge and belief, and I understand that a false statement is cause for denial, suspension, or revocation of a class approval. ___________________________ ______________________________ Date Instructor's Name (print) ______________________________ Instructor's Signature I hereby certify, under penalty of perjury, that the above information is true and correct to the best of my knowledge and belief, and I understand that a false statement is cause for denial, suspension, or revocation of a bail bond license. _____________________________ ______________________________ Date Agent's Name (print) ______________________________ Agent's Signature