Division of Insurance CONTINUING EDUCATION COURSE COMPLETION CERTIFICATE FORM CE-03, REVISED 1/5/05

INSTRUCTIONS: PLEASE READ CAREFULLY! 1. This Course Completion Certificate MUST be completed and typed by the Sponsoring Entity/Course Provider and signed by its authorized representative. It is imperative that the course approval number issued by the Colorado Division of Insurance be accurately entered on this form, including the dashes. It is also imperative that the course completion date be the exact date the producer successfully completed the course. 2. Continuing education (CE) course providers must submit, on no less than a monthly basis, a course roster, for each course taught, of all producers and the amount of continuing education credit received to Promissor, the outside vender contracted to process Colorado’s CE credits. Producers are no longer required to submit their CE credits to Pearson Vue, as it is the responsibility of the course provider to submit the CE credits. Prior to a producer’s license continuation date, Pearson Vue will provide the producer with a CE transcript of all CE courses taken and the number of credits received. It is the producer’s responsibility to verify the transcript and to advise Pearson Vue at 1-800-275-8247 of any discrepancy. 3. Producers must keep this Course Completion Certificate for a minimum of five years. DO NOT FORWARD THIS CERTIFICATE TO THE DIVISION OF INSURANCE OR TO PEARSON VUE.

Producer Name (As it appears on the Producer License) Number I,

Authorized Representative (type in name)

of

Sponsoring Entity/Colorado Continuing Education Course Provider

Producer License

Authorized Representative (Signature)

Provider Number

certify that the individual named herein has successfully completed the following educational course as approved by the Colorado Division of Insurance. Course Title: COLORADO COURSE APPROVAL NUMBER: COURSE COMPLETION DATE: Number of Credit Hours Earned: 07/2012

Continuing Education Course Completion Certificate.pdf

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