ARKANSAS INSURANCE DEPARTMENT

APPENDIX C CONTINUING EDUCATION PROVIDER APPLICATION

Name of Provider:

Address: Street or P.O. Box City State Zip

Phone Number: Fax #

Name of Contact Person #1

Contact Person Phone # Fax #

Contact Person E-mail:

Name of Contact Person #2 Contact Person Phone #

Contact Person E-mail: Fax #

What other States are you approved as a Provider of Continuing Education:

List Representatives Authorized to Sign Certificates for Provider:

Name	Title	Signature
Name	Title	Signature
Name	Title	Signature

Type of Courses Provider Will Offer: (check all that apply)

☐ Producer (agent/broker) ☐ Title Adjuster

Signed

Printed Name

Title

Dated

THIS FORM IS TO BE SUBMITTED WITH A REGISTRATION FEE OF $100

For Department Use:

Fee Received: Check or Route Slip:

Approved by Date:

Disapproved by Date: