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Ethics
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Continuing Education Agency Application
2023 Agency Renewal Letter-Live 3rdfloor
Continuing Education Agency Application
Agency Name:
(Required)
Address
(Required)
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Contact Person:
(Required)
First
Last
Email:
(Required)
Phone:
(Required)
FAX:
Website:
How long has the agency been providing trainings?
(Required)
How long has the agency been in existence?
(Required)
Is there usually a charge for trainings?
(Required)
Yes
No
Are attendees provided a certificate after the training?
(Required)
(Certificates must include agency name, seminar title & date, attendees name, number of contact hours, and an authorized signature)
Yes
No
How will you verify attendance at trainings provided?
(Required)
How will you evaluate the effectiveness of trainings provided?
(Required)
$100 (1 Conference) an additional $100 for each additional conference
(Required)
The number of trainings is an estimate for the year. If your agency does less than paid for, no refunds will be given. If you go above the number of approved trainings, the additional fee will be due at such point.
Price:
$100.00
Quantity:
Please Return This Application With The Appropriate Fee:
(Required)
The number of trainings is an estimate for the year. If your agency does less than paid for, no refunds will be given. If you go above the number of approved trainings, the additional fee will be due at such point.
We don't plan to have any trainings.
$300 (1-5 Trainings)
$400 (6-10 Trainings)
$500 (11-15 Trainings)
$600 (16-20 Trainings) $700 (21-25 Trainings)
$750 (26+ Trainings)
If interested in also providing preapproved online trainings in addition to live trainings:
(Required)
I am not interested in online trainings
$100 (Online Trainings)
Total
Credit Card
Card Details
Cardholder Name