Credit Reporting Form Page 2
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1
2Mandatory Continuing Education for Psychologists (MCEP)
MCEP ACCREDITING AGENCY
Credit Reporting Form
1231 I STREET, SUITE 204
SACRAMENTO CA 95814-2933
TEL: (916) 286-7980
FAX: (916) 286-7985
BOX FOR OFFICE USE ONLY
This Form is used to report courses that are not directly reported to MCEP for you. These include courses presented by APA,
CMA, ACCME, and ABPP CE Sponsor Organizations. If you need further assistance with this report, call the number above.
Submit this form with a copy of your attendance certificate or letter of completion for each course listed (do not send
original certificates) and the regulated $35 filing fee. Mail or fax to the above address. Do not both mail and fax
information. Once your report is processed we will mail you an updated copy of your educational record, please
look over this record and make sure it matches what you sent in. 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.
PLEASE PRINT LEGIBLY
Date:
Lic. #: PSY
Lic. Expiration Date:
Last Name:
First Name:
Email Address:
Date
Independent Learning
Course Title
# Hours
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
10
**The regulated $35 filing fee must be enclosed in order for this report to be processed.
Make checks payable to MCEP or fill out credit card information below with a signature authorizing us to
charge your card.
Payment Type
Credit Card #
:_________________________________________________________________
Visa, Master Card, American Express, Discover -
Expiration Date: ____________________
Verification Code: ____________________
Signature: ______________________________________________________________________
Phone:
Fax: (optional)
Billing Address:
City:
State:
Zip:
Form 07 BOP 15 (revised 9/2011)
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