Verification FormCOURSE ATTENDANCE VERIFICATIONParticipant’s Name:(Required)State and License #:Participant’s mailing address:(Required)Address City State / Province / Region ZIP / Postal Code Email(Required) Phone:(Required)Course Title:(Required)AGD ID#:(Required)Speaker Name (s):(Required)Educational Method:(Required)CDE Hours:(Required)Course Date: DD slash MM slash YYYY Course Times: Hours: Minutes AMPM AM/PMAGD Subject Code (s):(Required)Verification Code:
