Application for Continuing Education Credit

Description of Activities:



CEC Category:
A - Formal Educational Activity
B - Publications, Reports, Presentations
C - Professional Society Participation
D - Other Professional Activities

Type of Activity:


Duration of Activity:
Hours Semester Hours Days
Other:

Course Title or Activity:



Date(s) of Course or Activity:
Sponsoring Organization Name     
Address 
City      
State  
Zip       
Contact Person    
Telephone of Contact 
Requestor Information Name     
Address 
City      
State  
Zip       
Telephone  
Date  
Email Address  
Purpose of Request: Individual Use by Requestor For all Attendees Requesting 4-year Approval


A description of the course or activity needs to be attached to assist the Committee in its evaluation.
Include an Agenda or Schedule showing the number of hours for health physics activities.
After submitting this screen, be sure to upload the document(s) via the next screen to
complete the application.