Continuing Education Approval Request Form

This form must be completed in its entirety, and submitted either before or no later than 30 days after the completion of the activity.

Name

Address

City

State

ZIP Code

Email Address

Phone Number

Sponsor Name:

Contact Person:

Address

Email Address

Phone Number

Event Name/Title:

Date(s)

Time:

Presenter(s)/Instructor(s)

Website promoting the event:

Registration Fee:

General:

Ethics:

Language Specific

Copy of promotional materials advertising the event (required)

List of workshops and presenters (required for conferences and multi-day events)

Verification of registration in the event

Additional supporting information