Continuing Education Agency Application

2022 Agency Renewal Letter-Live 3rdfloor

Continuing Education Agency Application

Agency Name:(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Name:(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

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

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

Please Return This Application With The Appropriate Fee:(Required)

$300 (1-5 Trainings)

$400 (6-10 Trainings)

$500 (11-15 Trainings)

$600 (16-20 Trainings) $700 (21-25 Trainings)

$750 (26+ Trainings)

A 3% service charged will be applied to all payments made by credit card.(Required)

Price: $0.00

Total

Credit Card

Card Details

Cardholder Name