OTPTAT requires reporting of this information. Please fill out this form completely if you intend to apply for OTPTAT CEU credit.

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* 1. Last Name

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* 2. First Name

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* 3. Address

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* 4. Address 2

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* 5. Address 3

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* 6. City

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* 7. State

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* 8. Zip Code

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* 9. Country

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* 10. Email

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* 11. ID Number

Enter this information if you have a unique ID number, otherwise leave blank

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* 12. Please select the sessions that you attended (check all that apply):

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* 13. OTPTAT CEUs
Number of CEUs being applied for

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