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IA&B Webinar
CE Request and Enrollment Information Form
CPIA 3 - Sustain Success
May 7, 2026
(MUST BE COMPLETED BY ALL ATTENDEES)

PLEASE NOTE: A $25 fee (payable to the CPIA Program), 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.
1.First name(Required.)
2.Middle Name
3.Last name(Required.)
4.Are you requesting CE? (below is the list of approved webinar states)(Required.)
5.Check the box for the state for which you would like to receive CE credit.(Required.)
6.License and / or NPN (must be listed if requesting CE)
7.Birth Month(Required.)
8.Please check the appropriate box (select one)(Required.)
9.How did you hear about the CPIA program?(Required.)
10.What associations are you a member of?(Required.)
11.Agency / Company Name
12.Agency Principal / Manager
13.Agency Principal / Manager E-mail Address
14.Business Address
15.Home Address
16.Agency / Company Facebook Page
17.LinkedIn
18.Instagram