Application for Continuing Education

Attach:

Course Outline with Times

Curriculum Vitae or Resume for Each Instructor

 

Provider Information:

1. Sponsoring Organization or Individual:
2. Contact Person:
3. Telephone:
4. Mailing Address
5. Street Address (if different from mailing address):
6. E-mail:
7. Fax:

Program Information

1. Program Title:
2. Program Dates:
3. Total # of hours applied for:
4. Course Description:
5. Measurable Objective:

Faculty Names

1.

2.

3.

Evaluation Methods to be Used

1.

2.

3.

Attendance-Keeping Methods to be Used

1.

 

For more information connect to the Health Department: www.health.state