Name (as you want it to appear on your Certificate of
Phone Number (example 707-555-1234)
for this course, you must be able to provide identification
Your identification must be in your possession.
Identification Document (check one):
Expiration date (mm/dd/yy)
State (for driver license) or Country (for passport) where issued
The Secretary of State requires that the above information be collected and
stored for two years. This information will be kept confidential and will
only be used for purposes related to your use of this site. Any missing or
incorrect information may delay the issuance of your Certificate of
OF COURSE ATTENDEE
I am the
course attendee as noted on the above registration information and
that I, alone, will proceed through this online course for the
duration of the course.
identification information I provided on the registration form for
this course is true and accurate.
swear, under penalty of perjury, that the above statements are true
understand that the crime of perjury is punishable by imprisonment
in the state prison for two, three or four years. Penal Code §126
on the “I Agree Register Me” button below, I agree to be bound by the above
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