* denotes required field.

Continuing Education Hours Submission Application

(Please submit a new application for each course/program/published material)
First Name: *
Last Name: *
Company: *
Address: *
City: *
State: *
Zip Code: *
Phone: *
Email: *
Fax:  
CE Method: *  What's this?

Supporting Documents   What's this?
Agenda:  
Proof of Attendance:  
Published Material:  

Program Attended
Program Name:  
Date Attended:  

I attest that I have not been involved in any complaints or criminal, civil, self regulatory organization or government agency disciplinary actions(in the past two years) and to the best of my knowledge no complaints are about to be filed.


If you checked "Disagree" above, please submit a written summary of the incident(s) along with this form. If you have previously disclosed the incident(s) to CWS Board of Standards on a former application or CE submittal form and there is nothing new to report, you may check "Agree".
Incident Summary:  
Signature: *(Full Name)
Signature Date: *