California Code of Regulations › Title 10 - Investment › Chapter 5 - Insurance Commissioner › Subchapter 1 - Production of Insurance › Article 2.1 - Bail Education › Section 2105.17 - Prelicensing and Continuing Education Program Course Attendance Record and Verification Form

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
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
www.insurance.ca.gov
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.
1. New
					 section filed 8-20-2007; operative 9-19-2007 (Register 2007, No.
					 34).
Note: Authority cited: Section
						1812,
						Insurance Code. Reference: Section
						1810.7,
						Insurance Code.