APPENDIX E

INDIVIDUAL CERTIFICATE OF COMPLETION FOR USE WITH 23 CAR pt. 18

Producer Name (Type or Print)

Arkansas License Number(s)

Street Address

City

State

Zip Code

Authorized Representative (Type or Print)

of

Course Provider

do hereby certify that the person named herein has successfully completed the following approved courses:

Course Title

Number of Credit Hours Earned

Course Number

Date of Course Completion

This course has been approved by the Arkansas Department of Insurance pursuant to Rule 50.

Date

Signature of Authorized Representative

Date

Signature of Producer

THIS FORM MAY BE PROVIDED TO THE PRODUCER UPON COMPLETION OF THE COURSE IF REQUESTED BY THE PRODUCER.