PLEASE NOTE: A $25 fee (payable to the AIMS Society), the state filing fee (if applicable) and your state filing penalty (if applicable) will be charged for CE requests that are not submitted on the day of the class or if the information required on this form is not complete.

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* 1. First name

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* 2. Middle Name

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* 3. Last name

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* 4. Are you requesting CE? (below is the list of approved webinar states)

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* 5. Check the box for the state for which you would like to receive CE credit.

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* 6. License and / or NPN (must be listed if requesting CE)

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* 7. DOB

Date

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* 8. Please check the appropriate box (select one)

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* 9. How did you hear about the CPIA program?

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* 10. What associations are you a member of?

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* 11. Agency / Company Name

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* 12. Agency Principal / Manager

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* 13. Agency Principal / Manager E-mail Address

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* 14. Business Address

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* 15. Home Address

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* 16. Agency / Company Facebook Page

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* 17. Twitter

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* 18. LinkedIn

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* 19. Instagram

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