CE Certificate Request Form

District/Study Club Request for Verification of Participation Forms

This form must be completed at least 30 days prior to the scheduled CE event.

Name of District or Study Club

Organizer's Name

Organizer's Phone

Organizer's Email

Meeting or Presentation Title

Meeting Location

Meeting Date

CE Hours/Credits

Presenter's Name

Presenter's Title/Credentials

Presenter's Phone

Presenter's Email

Presentation Synopsis (or attach)

By submitting this form you are attesting and confirming that the CE event meets the minimum standards above.

I Attest and Confirm