Florida Association of Insurance Agents

Instructions:  Please fill in the information requested below.

 

ACKNOWLEDGMENT OF ATTENDANCE for an FAIA WEBINAR

Thank you for attending FAIA's webinar! We hope you enjoyed the class and that we will "see you" again soon!

Per DFS requirements, you must sign the acknowledgment below for us to process your CE.

This form must be sent to FAIA within three (3) business days.

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I certify for my official records that I attended the webinar listed below and did not leave the class for more than the time allowed for breaks (if any). By signing below I attest that I completed the entire class according to the standards required by Department of Financial Services in order to comply with the continuing education law for insurance. I certify that I am the person listed below and received no assistance of any kind for quizzes, tests or other confirmations of attendance. I understand the penalties for fraudulent certification of CE could result in disciplinary action by FL DFS.

Printable Form

* Indicates required field!
Your name as listed with FL DFS:	*
Student DFS License #:	*
	Check Box if Adjuster License
Please type your name again to serve as your electronic signature:	*
E-mail Address:	*
Please type your WITNESS name to serve as their electronic signature:	*
Webinar Name:	*
Webinar Course #:	*
Webinar Date:	*
Webinar Start Time:	*
Conference GROUP Setting? **	Yes   No
	**If yes, manager’s signature MUST be included here: (Manager may also be the witness to your signature above.)
Manager's Signature:

Please click submit only ONCE.