Licensing Course Statement of Completion

Once this form is submitted a staff member will review your eligibility to take the exam. You should receive an email within 1-2 business days with further instructions and verification code to schedule the exam.

Full Name

Email *

Date of birth

Phone *

Address

Street Address

City

State

Country

Postal code

Course Completed

Course Format

I certify that I have personally completed the required hours of my learning program as stated in license law 19 NYCRR SS 176.23; 177.22. I am aware that I must pass the course exam within one year of my purchase date and pass the state exam before I apply for my license.

Signature

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