1. State of Washington
Approved
Pre-License Education
CERTIFICATE OF COMPLETION
STUDENT NAME:STUDENT NAME:
PRELICENSE COURSE IDENTIFICATIONPRELICENSE COURSE IDENTIFICATION
Provider’s Name: INTELLIPASSProvider’s Name: INTELLIPASS
Provider’s Location: 1925 SOUTH 341ST
PLACE, FEDERAL WAYProvider’s Location: 1925 SOUTH 341ST
PLACE, FEDERAL WAY
Provider’s School Code Number: 12935Provider’s School Code Number: 12935
COURSE SUBJECT Credit Hours Completion DateCOURSE SUBJECT Credit Hours Completion Date
2020
Instructor: Instructor No.Instructor: Instructor No.
OROR
Self-Study Instructor No.Self-Study Instructor No.
INSTRUCTOR CERTIFICATIONINSTRUCTOR CERTIFICATION
I hereby certify this course was conducted as approved by the Washington State Office of the
Insurance Commissioner. I further certify the person whose name appears above did personally
complete this course on the date indicated.
I hereby certify this course was conducted as approved by the Washington State Office of the
Insurance Commissioner. I further certify the person whose name appears above did personally
complete this course on the date indicated.
Signature: Date:Signature: Date:
STUDENT CERTIFICATIONSTUDENT CERTIFICATION
I hereby certify that I personally completed the course listed above in the manner required to
satisfy the pre-license education regulation.
I hereby certify that I personally completed the course listed above in the manner required to
satisfy the pre-license education regulation.
Signature: _______________________________________ Date: ___________________Signature: _______________________________________ Date: ___________________
This certificate valid for 12 months from completion date. PLE-CERT (06-2009)This certificate valid for 12 months from completion date. PLE-CERT (06-2009)
Lynn Havens
Casualty 10/16/2015
9999
10/16/2015
Self-Study 9999