Retroactive Certification Application

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Complete a separate entry for each separate activity. CE Activity submissions will not be processed if forms are not completed correctly.

Applicant Information
Work setting *
Sponsoring Organization Information
Qualification of Instructor/s to teach MHC material (check at least one) *
Fill in the exact schedule below with the total instructional hours excluding registration, lunch and coffee breaks.  If the schedule is repeated more than one day, indicate the dates to the left. When a provider does not indicate a break in a four-hour period 15 minutes will be deducted from the time for a break period. When the provider does not indicate a lunch break in a workshop over 6 hours, one hour will be deducted for a lunch break. When the provider does not indicate a lunch break or other small breaks in a workshop 8 hours or more, a one hour lunch break and two 15 minute smaller breaks will be deducted from the original hours requested.

Does the activity description clearly indicate relevance to mental health practice? *

Fees: $25.00 for each application. $50.00 if submitted after October 15, of a renewal year (odd years) *
Current Total: