Your First Name Your Last Name Your Email Your Phone Number Date you took the LTC class Name of your LTC Instructor ---Henry AlvarezCharlie NguyenEdwina ParkerClinton RigginsI don't know the name of my Instructor Fee Schedule: $25 - form request within 60 days from date of taking class $50 - form request after 60 days from date of taking class By submitting this form I understand I will be charged a research and copy fee to provide me with a copy of my LTC 100 form, which will be payable prior to receiving my copy.
