Affidavit

Last Name (as appears on your license) *

First Name (as appears on your license) *

State(s) of licensure *

List all states/provinces where you are currently licensed.

Seminar Name *

Seminar Instructor(s) *

Seminar Start Date *

Month

Day

Year

Affidavit *

Check the box below to complete the Affidavit of Participation.

I confirm that I am the person who registered for this course and that I personally attended the entire course and completed all course materials, including any required readings, video, audio, or activities.

Comments

You are here