State of Alabama – Department of Insurance
Continuing Education Course Application
(Type or print all information)
PROVIDER INFORMATION:
Provider Name: ___________________________________________
Provider #: ___________________
Contact Person: __________________________________________
Phone #: _____________________
Address: _________________________________________________________________________________
(Street / Post Office Box)
_________________________________________________
______
___________
(City)
(State)
(Zip Code)
E-Mail Address: __________________________________________
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COURSE INFORMATION: Course offered to the public [ ] Yes
[ ] No
Proposed
Course Title: _______________________________________________________
Credit Hours: _____
Course Category: [ ] Life/Health
[ ] Property/Casualty [ ] General/Other [ ] Ethics
Study Method: [ ] Classroom
[ ] Self Study
[ ] Seminar [ ] Online/Computer
NOTE: If the above course is classroom or seminar - fill in the following information:
Instructor: ____________________________________ Location: _________________________________
City: _________________________________________ State: _____________
Zip Code: ________
Date: _____________
Start Time: ___________ Phone Number: ___________________________
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DEPARTMENT USE ONLY
Course Approved:
[ ] Yes
Course Disapproved:
[ ] Yes
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To complete the application process, the $50 application fee must be included. Mail to:
State of Alabama Department of Insurance
Continuing Education Section
201 Monroe Street, Suite 170