Cal. Code Regs. tit. 10 § 2105.17
| State of California | Department of Insurance |
| PRELICENSING/CONTINUING EDUCATION PROGRAM | |
| COURSE ATTENDANCE RECORD AND VERIFICATION FORM | |
| 446-5 (Rev. 6/2006) |
___________________________
Producer Licensing Bureau--Education Section
320 CAPITOL MALL
SACRAMENTO, CA 95814-4309
Information (916) 492-3064
| Course Number: | ___________________________ | |||
| Course Title: | ___________________________ | |||
| ___________________________ | ||||
| Provider Number: | ___________________________ | |||
| Provider Name: | ___________________________ | |||
| ___________________________ | ||||
| Class Location: | ___________________________ | |||
| Street | City | State | Zip Code | |
| Class Date(s): | ___________________________ | |||
VERIFICATION:
I have reviewed and verified that the persons named on the attached Course Attendance Record Sheet(s), consisting of ______ pages, were present at this class during the times and days indicated.
| ___________________________ | |
| Original Signature of Instructor | Date |
| ___________________________ | |
| Printed Name of Instructor | |
CERTIFICATION:
I have reviewed this Course Attendance Record Verification and the attached Course Attendance Record Sheet(s), and certify that I find them accurate and in order, to the best of my knowledge.
| ___________________________ | |
| Original Signature of Provider Director | Date |
| ___________________________ | |
| Printed Name of Provider Director | |
COURSE ATTENDANCE RECORD SHEET
| Provider #: | Provider Name: | Page of | |||||
| Course #: | Course Name: | ||||||
| Date: | Begin Time: | End Time: | Session of | ||||
| Location | Instructor: | ||||||
| Street | City | State Zip | |||||
NOTE: Those students who do not sign in and out will not be granted continuing education credit.
| TIME-IN: AM/PM | PRINTED NAME (LAST, FIRST M.I.) | SOCIAL SECURITY NUMBER* | INDIVIDUAL INSURANCE LICENSE # | TIME-OUT: AM/PM | SIGNATURE I CERTIFY UNDER PENALTY OF PERJURY THAT THESE ARE MY CORRECT ATTENDANCE TIMES. |
(ATTACH ADDITONAL SHEETS IF NECESSARY)
The Department requests disclosure of a student's social security number pursuant to Insurance Code Sections 1749, 1749.2, 1749.3, 1749.31, 1749.4, 1749.5, 1749.7, 1810.7 and CCR, Title 10, Chapter 5, Sections 2105.7(c)(1), 2105.10(b)(1), and 2188.5(b)(1). This information is requested so that the Department can properly identify and assign credit to students who have completed prelicensing or continuing education courses. While a student's disclosure of his or her social security number here is not mandatory, any failure to provide this information may delay or otherwise impede the Department in assigning credit for the completion of such courses to the appropriate students.
Cal. Code Regs. Tit. 10, § 2105.17
Note: Authority cited: Section 1812, Insurance Code. Reference: Section 1810.7, Insurance Code.