Credit Reporting Form
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Complete Credit Reporting Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
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1
2MCEP Credit Reporting Form Instructions
Please follow these step by step instructions when filling out your Credit Reporting Form.
Filling Out ONLINE VERSION
Filling Out PRINTED VERSION
Personal Information
PLEASE PRINT NEATLY
1. Type in the information requested.
Personal Information
Course Information*
1. Fill in the information requested.
2. Type the end date of your class
Course Information*
3. Mark yes or no for Independent
2. Fill in the end date of your class
learning (see definition below for
3. Mark yes or no for Independent
Independent Learning)
Learning (see definition below for
4. Type the class title
Independent Learning)
5. Type the class hours
4. Fill in the class title
5. Fill in the class hours
*
Please note that if it is a large conference
with one certificate listing your sessions, you
*
Please note that if it is a large conference
can just write in the title of the conference
with one certificate listing your sessions, you
and total number of hours. Basically we
can just write in the title of the conference
want one line on the Reporting Form for
and total number of hours. Basically we
every certificate you are sending us.
want one line on the Reporting Form for
** If you need more lines then just attach a
every certificate you are sending us.
second reporting form.
** If you need more lines then just attach a
second reporting form.
PAYMENT SECTION
6. Payment of $35 is required or your
PAYMENT SECTION
report will not be processed.
6. Payment of $35 is required or your
7. Use the arrow to select the Payment
report will not be processed.
type.
7. If paying by Credit Card then please
8. If paying by Credit Card then please
fill in the credit card information.
type in the credit card information.
8. The Verification Code is usually
9. The Verification Code is usually
found on the back of your card
found on the back of your card
9. You must sign if paying by credit
10. Type your contact information.
card.
11. Print the form
10. Fill in your Contact information.
12. Sign the Credit Card signature line if
paying by credit card.
THIS FORM CANNOT BE SUBMITTED ONLINE OR BY E-MAIL,
YOU WILL NEED TO EITHER FAX OR MAIL WITH COPIES OF YOUR
CERTIFICATES.
FAX: 916-286-7985 OR
MAIL TO: 1231 I STREET SUITE 204, SACRAMENTO, CA 95814
BILLING ADDRESS SECTION
We need your billing address or the credit card will not go through. If there is a problem with your payment
we will need to contact you by phone so please give us your phone number (MCEP staff use only, not
published). Your fax number is optional and will not be published. Please fill in the billing address for the
credit card you are using in the space provided.
INDEPENDENT LEARNING
Independent Learning hours “means the variety of forms of organized and directed learning experiences
that occur when the instructor and the student are not in direct visual or auditory contact” For further
information please see our website.
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