Affidavit of Webinar Attendance Form

Please complete the Affidavit of Webinar Attendance Form for each registered student that is requesting Wisconsin credit. A single form may not be used to acknowledge the attendance of more than one registered student. This form must be COMPLETED IN FULL by the attendee. Failure to complete this form and return within the allotted amount of time may result in loss of credit.

Fields marked with an * are required.

Attendee Information

First Name *

Last Name *

License/NPN Number *

Webinar Information

Webinar Course Title *

Course Number of Days *

Webinar Day One Information

Date of Webinar Day One *

Webinar Start Time *

Please enter the time of the course start in the following format (HH:MM AM/PM)

Webinar End Time *

Please enter the end time of the course in the following format (HH:MM AM/PM)

Webinar Day Two Information (If Applicable)
Only enter information in this section if the webinar had a second day of instruction.

Date of Webinar Day Two

Webinar Start Time Day Two

Please enter the time of the course start in the following format (HH:MM AM/PM)

Webinar End Time Day Two

Please enter the end time of the course in the following format (HH:MM AM/PM)

Acknowledgement of Personal Responsibility

Acknowledgement of Personal Responsibility *

I certify that I personally participated in and attended all sessions of the Webinar course referenced above.

Signature (Type First and Last Name) *

Today's Date *

To ensure CE for this webinar, this form must be completed and submitted the day of the course and no later than 30 minutes after the conclusion of the course.
Thank you.

Affidavit of Webinar Attendance Form

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