2024 Training Approval Application

Title of workshop, program, or seminar, etc.:(Required)

We would like to request the MCB advertise this training(Required)

Yes

Location Name:(Required)

Location Address:(Required)

Street Address Address Line 2 City State ZIP Code

Date(s) of Training:(Required)

Time of Training:(Required)

Contact Hours:(Required)

Price of Training:(Required)

Agency:(Required)

Provider Status Number:(Required)

Contact Person:(Required)

First Last

Email:(Required)

Phone:(Required)

FAX:

Address:(Required)

Street Address Address Line 2 City State ZIP Code

Website:

Present(s) & Credential(s):(Required)

General description of training:(Required)

Please enclose a copy of the agenda or a flyer regarding the training.:

Drop files here or

Accepted file types: jpg, jpeg, pdf, doc, docx, Max. file size: 100 MB, Max. files: 5.

*****Agencies must provide participants with a certificate which includes the sponsoring agency name, title and date of the training, participant’s name, number of contact hours and an authorized signature.*****