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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