WYOMING CONTINUING EDUCATION COURSE VERIFICATION FORM
FULLY COMPLETE AND SIGN THE FORM BELOW
1. Please indicate if this is a change of resident address.
2. Enter the Wyoming provider course ID number, name of sponsor and exact course title, and credit hours.
3. Attach copies of course completion for each course. Non Resident Adjusters may attach current original
letter of certification from home state Insurance Department.
4. Credit will only be given for those courses completed during the current year.
5. The required ten hours must be completed prior to sending this form to the Wyoming Insurance
6. Attach the required $15 fee.
7. Return this form, prior to December 31 of each calendar year, to the Wyoming Insurance Department,
106 East 6th Avenue, Cheyenne, Wyoming 82002.
Name Work Telephone
Resident Address Social Security No.
City, State, Zip Date of Birth
Check box if a change of resident address Check box if current original letter of certification
is attached in lieu of course certification
Continuing Education Courses Completed
Provider Course ID No. Sponsor/Exact Course Title Date Completed Credit Hrs.
I certify to the best of my knowledge that the above is true and accurate.
CE 301 (Rev. 08/02)