CLE Approval Form for Approved Providers

Applicant Details

Organization:
First name:
Last name:
Phone number:
Preferred E-mail:
Please note that CLE application approvals are sent by e-mail - make sure we can reach you!
Mailing Address:
City:
State Abbreviation:
Zip code:

Activity Details

Activity you are seeking CLE credit for: New offering
additional instance of previously-approved offering
Type of activity (select all that apply) On-site presentation (live)
Webinar (live)
Webcast (recorded)
Audio Teleconference (live)
Self-Study (additional $20)
Title of Presentation:
Topic:
(if unclear from title)
Date of activity:
(only if multi-day) End date of activity:
Length of activity in hours:
(do not include breaks or meals)
Number of General credits requested:
Number of Ethics credits requested:
(if applicable)
Location (city, state or online) of Presentation:
Web address of this event's information page:
Supporting Document(s):
submit in PDF format
  • Speaker resumes or bios
  • Course description/schedule breakdown
  • Promotional material/advertisement (optional)


Total: $0

Pay by: Pay by Credit Card
Pay by Check

If you wish to keep a copy of this form for your records, please print it now before submitting.

modified 10/8/2014

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