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UNIFORM CONTINUING EDUCATION RECIPROCITY COURSE FILING FORM Please clearly print or type information on this form. Thank you for helping us promptly process your application. Provider Information
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What is Provider NameFEIN # (if applicable) Form?

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Provider name/FEIN refers to the legal name or Federal Employer Identification Number of the service provider, if applicable.
Service providers or businesses may be required to provide their name or FEIN for tax or identification purposes.
The provider name or FEIN can typically be filled out on a form or document where it is requested.
The purpose of providing the name or FEIN is to correctly identify the service provider for legal or tax reasons.
The information reported may include the legal name of the provider and their unique Federal Employer Identification Number.
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