Free 39287.PDF - Indiana

INDIANA COMMISSION ON PROPRIETARY EDUCATION VERIFICATION OF AGENT TRAINING
State Form 39287 (R5 / 9-99)

Name of applicant agent

Name and location of institution

Date submitted

TYPE OF TRAINING RECEIVED BY THE APPLICANT AGENT:
1. Classroom?

Yes

No

(a) Give number of hours of classroom training:

2. Field training?

Yes

No

(a) Give number of hours field training:

(b) Name of individual who supervised training:

(c) Give explicit description of the field training:

3. Indiana Code 20-1-19 and Rules and Regulations? (a) Number of hours in training:

Yes

No

4. Course content?

Yes

No

(a) Number of hours in training on course content:

5. Total hours of training received prior to submission of this form:

I hereby swear or affirm that the information supplied on this form is true.
Signature of applicant

STATE OF

Indiana

COUNTY OF

}

SS:

Subscribed and sworn to before me this ___________________________ day of _____________________________________________ , __________ .
Signature of Notary Printed name of Notary

My Commission expires:

County of residence:

The undersigned hereby certifies that the applicant agent has been thoroughly trained and understands Indiana Code 20-1-19, the Rules and Regulations of the Indiana Commission on Proprietary Education and the correct appeal procedures in the event of agent license suspension. (Reference 570 IAC 1-5-4).
Signature of Training Supervisor Printed name and official capacity

STATE OF COUNTY OF

}

SS:

Subscribed and sworn to before me this ___________________________ day of _____________________________________________ , ___________.
Signature of Notary Printed name of Notary

My Commission expires:

County of residence: