Exam Integrity – Why It Matters CE Form Exam Integrity – Why It Matters Name(Required) First Middle Last Address(Required) Street Address City State / Province / Region ZIP / Postal Code Phone(Required)Email(Required) May we text you?(Required) Yes No Name of Business or Employer(Required)Title(Required)WebsiteRegulatory Board AffiliationNumber of years served with regulatory affiliationRegulatory ExperienceLegislative ExperienceOther Affiliation(s)/ExperienceIn an effort for committees to reflect the diversity of our membership, please provide demographic information (optional) American Indian, Alaska Native, or Indigenous Peoples Hawaiian or other Pacific Islander Asian or Asian American Black or African American Caucasian Hispanic or Latino Other Current License(Required) Funeral Directing Embalming Both Not Currently Licensed List jurisdictions licensed in(Required)Educational Background(Required)Please check all that apply to your board/agency/bureau:(Required) Single License Jurisdiction Dual License Jurisdiction Autonomous Board Governed Agency Governed Bureau Governed Consumer Member Health Regulated Board Business Regulated Board I have access to:(Required) High-speed internet Laptop computer None Attestation(Required) I attest I am the individual listed above.
