License Registration - AAC Info Network

Which seminar are you attending?

First Name (required)

Last Name (required)

Your Email (required)

License Number (required)

Street (required)

City (required)

State (required)

Zip (required)

Electronic Signature (required)

By checking this box you are agreeing to electronically sign this form and declaring under penalty of perjury, that you personally attended the stated course, on the listed date(s) and you personally attended the listed hours of coursework.