Application For License Renewal Form Page 3
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3CONTINUING EDUCATION FORM
copies of the Certificates of Completion
List each of the courses completed and submit
for the courses listed. Courses submitted for
continuing education hours, which are approved by the National Certification Board or the National Certification Commission for Acupuncture
MUST
and Oriental Medicine,
include the approved provider number of the course provider. This page must be completed, signed and dated;
(You may photocopy this page)
otherwise it will be considered an incomplete renewal application and returned to you.
(Check
ALL
Blocks That Apply To This Course)
□
□
Course Title:_____________________________________________________
or
NCBTMB
NCCAOM
□
Approved Provider Number:
_____________________________________________
College / University Course
□
Location (City, State): _____________________________________________
Classroom Instruction
(If course is home study or distance learning, leave location blank)
□
Distance Learning/Home Study
Instructor’s Name: ________________________________________________
□
Ethics
Date Course Completed: ___________________________________________
Total CE Hours for this Class:_______
(Check
ALL
Blocks That Apply To This Course)
□
□
Course Title: ____________________________________________________
NCBTMB
or
NCCAOM
□
Approved Provider Number: ________________________________________
College / University Course
□
Classroom Instruction
Location (City, State): _____________________________________________
□
(If course is home study or distance learning, leave location blank)
Distance Learning/Home Study
□
Instructor’s Name: ________________________________________________
Ethics
Date Course Completed: ___________________________________________
Total CE Hours for this Class:_______
(Check
ALL
Blocks That Apply To This Course)
□
□
Course Title: ____________________________________________________
NCBTMB
or
NCCAOM
□
Approved Provider Number: ________________________________________
College / University Course
□
Location (City, State): _____________________________________________
Classroom Instruction
(If course is home study or distance learning, leave location blank)
□
Distance Learning/Home Study
Instructor’s Name: ________________________________________________
□
Ethics
Date Course Completed: ___________________________________________
Total CE Hours for this Class:_______
(Check
ALL
Blocks That Apply To This Course)
□
□
Course Title: ____________________________________________________
NCBTMB
or
NCCAOM
□
Approved Provider Number: ________________________________________
College / University Course
□
Classroom Instruction
Location (City, State): _____________________________________________
(If course is home study or distance learning, leave location blank)
□
Distance Learning/Home Study
Instructor’s Name: ________________________________________________
□
Ethics
Date Course Completed: ___________________________________________
Total CE Hours for this Class:________
By my signature below , I certify all inform ation contained in this Application
for License Renew al and all supporting documentation is true and valid.
Total CE Hours This Page: _______
TOTAL CE HOURS SUBMITTED
_____________________________________________ _______________
FOR THIS RENEWAL PERIOD:
________
Signature
Date
3
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