Mcep Credit Reporting Form printable pdf download

Mcep Credit Reporting Form

MCEP ACCREDITING AGENCY

Mandatory Continuing Education for Psychologists (MCEP)

3835 North Freeway Blvd., Suite 240

MCEP Credit Reporting Form

SACRAMENTO CA 95834-1955

TEL: (916) 286-7980

FAX: (916) 286-7985

This Form is used to report courses that are directly authorized for MCEP credit by law or BOP regulation rather than by

a recognized accrediting agency. The purpose of this report is to integrate MCEP credit from all sources into one

complete record for each psychologist. If you need further assistance with this report, call the accrediting agency at the

number above.

Date:

Lic. #: PSY

Lic. Renewal Date:

Last Name:

First Name:

Phone:

Fax:

Address:

City:

State:

Zip:

Email Address: (optional)

Date

Distance Learning

Course Title

# of Credit Hours

Yes / No

A copy of an attendance certificate or letter of verification must be submitted for each course listed. Please do

not send original certificates. Licensee must retain proof of attendance in the event the Board of Psychology

requests verification. If more room is needed to list courses, please attach additional copies of this form.

*Make checks payable to MCEP in the amount of $35 and mail to the above address. You may also pay by

Credit Card. Faxed reports must include a charge payment to be processed. Please do not both mail and

fax information. We will mail you an updated copy of your educational record when the form is

processed.

Credit Card #:_________________________________________ Expiration Date: _______________________

Signature: _________________________________________________________________________________

**The regulated $35 filing fee must be enclosed in order for this report to be processed.

Form 07 BOP 15 (new 06/04)

Mcep Credit Reporting Form