Continuing Education Agency Application

Agency Name:(Required)

Address(Required)

Street Address Address Line 2 City State 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 Quantity(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

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428 East Capitol
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Jefferson City, Missouri 65101
573.616.2300
help@missouricb.com