1. The course was completed (month) (day) , (year) .
(please, use the date from the completion certificate)
2. I am a Montana Insurance Producer Yes No
3. I am a Montana Insurance Consultant Yes No
4. I am a Montana Insurance Adjuster Yes No
5. This was a college or university course Yes No
If, yes, name of college or university
6. The course was taught in this method:
Classroom (an instructor or instructors taught the course materials).
Correspondence (I studied a book and completed and passed a test).
Videotape (I watched a videotape and completed and passed a test).
Audiotape (I listened to an audiotape and completed and passed
a test).
Teleconference (I went to a scheduled teleconference site that was
monitored by the course provider).
Other (I completed a computer-based course and completed and
passed a test) or (write a description of the method)
7. The name(s) of the instructor(s) is/are:
.
