APPLICATION FOR APPROVAL OF A CONTINUING EDUCATION COURSE
APPLICATION FOR
PGH OR CE COURSE APPROVAL
| Please check one or both: |These items must be attached for application to be considered: |
| |Timed agenda |
| |Instructor’s Bio |
|Water: Sonya McLamb |Class schedule for course (date, time, location, etc.) |
|1635 Mail Service Center |Sample certificate of completion |
|Raleigh, NC 27699-1635 OR | |
|sonya.mclamb@ | |
| | |
|Wastewater: Maureen Kinney | |
|1618 Mail Service Center | |
|Raleigh, NC 27699-1618 OR | |
|maureen.kinney@ | |
|Name of Organization providing course: | |
|Responsible Person (First MI, Last): | |
|Address: | |
|Phone No.: |( ) |Email: | |
|Proposed |Brief Course Description ~ OR ~ Attach Brochure |Contact Hours Requested |
|Course Title | | |
| | | |
|List the course goals (What competencies will be gained from the course?): |
| |
|List educational materials to be used (publications, manuals, handout, slides, etc.): |
| |
I affirm I have read and understand the policy document for training providers and will comply with all requirements as set forth within. Also, I understand that the Operator Certification Program may audit any approved course at its discretion.
Applicant's Signature: Date:
................
................
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