National Insurance & Healthcare Continuing Education
Schedule and Onsite Program
Required fields are marked with
*
Date of Course Requested
*
mm/dd/yy
Time Requested
Location Name
*
Location Contact Name
Location Email
Location Phone
Location Address
*
City
*
State
*
Zip
Number of Expected Attendees
License Type of Attendees
(ex. nurse, adjuster, attorney, CCM, etc.)
Topic Request: First Choice
Topic Request: Second Choice
State Credit(s) needed
(Ex: FL, NC)
Sponsor (1)
Sponsor (2)
CEUI to arrange for a speaker?
Yes
No
Person Making Request Information
Person Making Request Name
*
Requestor's Phone
*
Requestor's Email
*
Notes and Further Instructions
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