THIS  FORM  IS  NOT  PROOF  OF  CONTINUING  EDUCATION  CREDIT.  TO  RECEIVE  CONTINUING  EDUCATION  CREDIT  YOU  MUST:  

1. Fill  out  this  form  in  its  entirety  and  sign  below  certifying  that  you  have  completed  the  course  and  read  all  applicable  material.  2. Please  send  a  faxed  copy  of  the  completed  form  to  Affective  Learning  Labs  (Attn:  Course  Administration)  at  410-­‐329-­‐1102.  3. Once  we  have   received  a   copy  and  confirmed  your   course   completion,   a   final  Certificate   of  Completion  will   be   sent   to  you   for  proof   of  

continuing  education  credit.    

Student’s  Full  Legal  Name:  ____________________________________________________________________    Student  Certificate  #:                            Address:                              City,  State,  Zip                                I  affirm  that  the  work  submitted  herin  is  my  own  work  and  that  no  one  assisted  me  with  completion  of  the  examination.    Signature  of  Student:                            Print  Name:                              Date: