Cal. Code Regs. tit. 10 § 2105.16
| State of California | Department of Insurance |
| Class Presentation Schedule | |
| 446-12 (Rev. 11/2000) |
___________________________
Producer Licensing Bureau--Education Section
320 CAPITOL MALL
SACRAMENTO, CA 95814-4309
Information (916) 492-3064
Instructions:
* Type or print clearly. USE A SEPARATE SHEET FOR EACH CLASS PRESENTATION.
* To inform the Department of a new class, mark NEW box and provide all pertinent information below.
* To notify the Department of a change to a class schedule previously submitted, mark CHANGE, give the original date, time, location and provide new information below.
* To cancel a class previously submitted, mark CANCEL and complete information below.
* This completed form must be received by the Department at least 14 days prior to the original class presentation. Subsequent presentations must be received at least 10 days prior to class presentation. No faxes will be accepted.
* Late schedules may not be accepted and attendees may not receive continuing education credit.
* The information provided below must match the information on the certificate of completion and the provider roster.
| CHECK ONE: New [] Cancel [] Change [] | Original Date/Time: |
| Original Location: | |
| Provider ID #: | |
| Provider Name |
| Course ID#: | Credit Hours: | Instructor Name: | |
| Course Name: | |||
| Start Date*: | Start Time: | End Date: | End Time: |
| Military Time | Military Time |
*If course spans more than one day, each day must be listed in Daily Presentation Schedule chart below.
Location of Presentation:
| Street: | Room/Suite: | |
| City: | State: | Zip: |
Daily Presentation Schedule: Times must be shown in military time (i.e. 8:00 AM = 0800; 2:00 PM = 1400)
| Day | Date: (month/day/year) | Begin Time | End Time |
| Day 1 | |||
| Day 2 | |||
| Day 3 | |||
| Day 4 | |||
| Day 5 | |||
| Day 6 | |||
| Day 7 | |||
| (Attach sheet for additional days) | |||
I certify that the class information provided here is true and correct to the best of my knowledge. Any changes will be provided to the Department promptly.
| ___________________________ | |
| Original Signature of Provider Director | Date |
| ___________________________ | _____ (____) ___________________________ |
| Printed Name of Provider Director | Phone Number |
Cal. Code Regs. Tit. 10, § 2105.16
Note: Authority cited: Section 1812, Insurance Code. Reference: Section 1810.7, Insurance Code.