SAFE-D Webcast Credit Application

SAFE-D Credit Application
I certify that I participated in the Health Insurance webcast of Sept. 25, 2023 and am entitled to receive one (1) hour of ESD Commissioner Training Credit. I understand that false statements on this application may lead to significant penalties.

In the blank below, fill in the keyword supplied during the webcast. The keyword is required for the credit application to be processed.

Please allow 6-8 weeks for credit processing.
Keyword*
Name*

First NameLast Name
E-mail*
County*
ESD Name*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Please rate the value of this training

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Please rate the TECHNICAL QUALITY of this training

Good video/Good audioGood video/Fair audioGood video/Poor audioFair video/Good audioPoor video/Good audioOther
Comments about this training?
Use your mouse (on your PC) or your finger (on your mobile device) to sign the form.
Signature

Clear
NEW: BEFORE you click SUBMIT below, click the PRINT FORM button (below) to print the form for your records until you receive an emailed form from VG Young Institute.
Once you hit the SUBMIT button below, you will see an acknowledgement page.

This form will be available for 30 days after the training. After 30 days, credit application will not be available. Please note: Payment must be received for credit hours to be processed. Educational sponsor: V.G. Young Institute of County Government, Texas A&M AgriLife Extension Service.
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SAFE-D Credit Application