General Information

Please complete all sections of the application. A fee of $150.00 is to be paid at the time of application. Applications are reviewed by the Board at its regularly scheduled meetings. (Meeting dates: Board Calendar)

Application Procedure

During the application process, the Board will evaluate the suitability of your organization to serve as an Approved Sponsor. The information submitted will enable the Board to evaluate your qualifications for sponsorship.

Name of Applicant

Contact Person:

MAILING ADDRESS

Street:

City/State/Zip:

PHYSICAL ADDRESS

(leave blank if same as mailing address)

Street:

City/State/Zip:

Phone:

Fax:

Email:

Web address:

Organizational Type:

Course Type(s):

Video

Correspondence

Internet

Audio Tapes

Seminars Only (Attendance required)

Other

Program Offerings:

Courses/activities will be offered to:

CERTIFICATE OF COMPLETION

Provide persons completing the course with written documentation attesting to that person’s attendance, as well as the name of the course, the date and location, the instructor’s name and the number of PDHs earned. You may submit a copy of an example. See example