ELECTRONIC COURSE COMPLETION FORM
Thank you for your enrollment in this Institute of Addiction Awareness
HOMESTUDY Program.
We hope you will enjoy your participation in this course.
INSTRUCTIONS:
1. Read course text.
2. Take Post Test using Answer Sheet.
3. Verify Post Test responses by reviewing course text.
4. Complete this form (return original - keep a copy for your files).
5. Mail or FAX to:
Institute of Addiction Awareness
190 Red Rock Trail
Sedona, AZ 86336
FAX 928-550-4926 (must FAX both pages)
INFORMATION: The following information is necessary for the issuance
of your certificate.
PLEASE TYPE OR PRINT NEATLY!
Course Title ______________________________________
Date Started ____________
Name _________________________________________
Address ___________________________________________
City/State/Zip____________________________________________
Phone: home ___________________ work _____________________
Lic.: Type _____________ # _____________
Cert.: Type ______________ # ____________
Email: _______________________________
Firm: _______________________________
EVALUATION: Please evaluate your course using this scale:
1=below average 2=average 3=above average 4=excellent
1 2 3 4 The extent to which this course met the objectives (see catalog).
1 2 3 4 The adequacy of the instructor's (author) mastery of the subject.
1 2 3 4 The utilization of appropriate teaching methods (HOMESTUDY).
1 2 3 4 Efficiency of course mechanics (mail order procedures).
1 2 3 4 The applicability or usability of new information.
Additional Comments:
_______________________________________________________
_______________________________________________________
_______________________________________________________
Please allow IAA 10 working days for the processing of your certificate.
If you need more rapid processing see OVERNITE FAX-BACK below.
Courses completion date(s) are the date FAXed or postmarked to IAA.
No duplicate certificates issued after 60 days from completion without
additional fee.
( ) Return certificate by mail (to address above)
-OR-
( ) Return certificate by FAX to: ( ) _________________________
( ) FAX BACK service - your exam scored and certificate
FAXED next business day - \$10.00 surcharge
NOTE: There is a $5.00 surcharge for mail and FAX service outside the USA.
Credit Card ( ) VISA ( ) MC ( ) AMEX ( ) DISCOVER
Card # ___________________________
Exp. Date ________________________
Authorized Signature __________________________________
( ) US NAVY/MARINE personnel - check here to receive required
critique form.
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Post Test Answer Sheet - Circle Correct Answers
01. a b c d 26. a b c d 51. a b c d 76. a b c d
02. a b c d 27. a b c d 52. a b c d 77. a b c d
03. a b c d 28. a b c d 53. a b c d 78. a b c d
04. a b c d 29. a b c d 54. a b c d 79. a b c d
05. a b c d 30. a b c d 55. a b c d 80. a b c d
06. a b c d 31. a b c d 56. a b c d 81. a b c d
07. a b c d 32. a b c d 57. a b c d 82. a b c d
08. a b c d 33. a b c d 58. a b c d 83. a b c d
09. a b c d 34. a b c d 59. a b c d 84. a b c d
10. a b c d 35. a b c d 60. a b c d 85. a b c d
11. a b c d 36. a b c d 61. a b c d 86. a b c d
12. a b c d 37. a b c d 62. a b c d 87. a b c d
13. a b c d 38. a b c d 63. a b c d 88. a b c d
14. a b c d 39. a b c d 64. a b c d 89. a b c d
15. a b c d 40. a b c d 65. a b c d 90. a b c d
16. a b c d 41. a b c d 66. a b c d 91. a b c d
17. a b c d 42. a b c d 67. a b c d 92. a b c d
18. a b c d 43. a b c d 68. a b c d 93. a b c d
19. a b c d 44. a b c d 69. a b c d 94. a b c d
20. a b c d 45. a b c d 70. a b c d 95. a b c d
21. a b c d 46. a b c d 71. a b c d 96. a b c d
22. a b c d 47. a b c d 72. a b c d 97. a b c d
23. a b c d 48. a b c d 73. a b c d 98. a b c d
24. a b c d 49. a b c d 74. a b c d 99. a b c d
25. a b c d 50. a b c d 75. a b c d 100 a b c d
Statement: I certify that I have completed this independent study program
according to the instructions provided and that all work is my own.
Signature ____________________________ Date ___________
NOTE: Orders paid by personal check will be held for two weeks.
