Form 5434-A (Rev 1-2023)-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your last prefix and enrollment number in the designated fields at the top of the form.
3. Fill out your personal information, including your last name, first name, middle name or initial, business name (if applicable), address, city, state, ZIP code, daytime phone number, and email address.
4. Indicate if any of your information has changed since your last submission by checking the appropriate box.
5. Complete Items A-C under Section 3 by entering total credit hours for qualifying professional education in each category. Ensure you provide details for each sub-item listed.
6. Answer Item D regarding completion of required continuing professional education credit hours by checking 'Yes' or 'No'.
7. Proceed to Section 4 and check one box for each question regarding any findings from authoritative bodies or criminal offenses.
8. Finally, sign and date the declaration in Section 5 to confirm that all information is true and complete before submitting your form.

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