Continuing Education Course Application - Individual Form
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1BOARD OF EXAMINERS OF NURSING CARE INSTITUTION ADMINISTRATORS AND
ASSISTED LIVING FACILITY MANAGERS
1400 West Washington, Suite B - 8
Phoenix, Arizona 85007
(602) 364-2374 phone
(602) 542-8316 fax
Douglas A. Ducey
Allen Imig
Email:
information@aznciaboard.us
Governor
Executive Director
Website:
Continuing Education Course Application – Individual
Name: _____________________________________________License/Certificate #: _________________________________
Address: _______________________________________ City: _______________ State:_________ Zip Code: _____________
Telephone: ____________________Fax: ______________________E-Mail: __________________________________
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Administrators
Managers
This course is for:
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Classroom
Online
Webinar
Self Study
Other ______________
Teaching Method (Select Only One):
Sponsor: ______________________________________________________________________________________________
Title of Course:_________________________________________________________________________________________
Requested Hour(s) _______________
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Statutes/Rules
Principles of Management
Psychology
Patient Care
Subject Areas of Course:
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Personal/Social Care
Therapeutic/Supportive/Nutrition/Pharmacology/Disease
Resources
Patient Rights
Date Course offered: _______________________________________________________Time: _______________________
Location Address: _____________________________ City: _______________ State:___________ Zip Code: _____________
Instructor: ____________________________________________________________________________________________
Signature:_____________________________________________________________Date:____________________________
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$5.00 Per Hour Requested
Instructor Curriculum Vitae
Course Objective
Required Attachments:
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Copy of teaching material
Course outline/brochure showing times and breaks
Copy of test or evaluation
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Copy of Certificate of completion that complies with R4-33-501 (D)
Money Order or Certified Check Only, made payable to “NCIA Board”
FOR OFFICIAL USE
Received Date:___________________
Receipt #: _______________________ Amount: _____________________
Approved Date:__________________
Expiration Date:__________________
Course Approval #: ______________________________________________ Hours Approved:__________________________
Approved By:
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