Ncsb Form 3 - Bar Member'S Application For Cle Credit
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2NCSB Form 3 rev. 1/2016
THE NORTH CAROLINA STATE BAR
FOR OFFICE USE ONLY
BOARD OF CONTINUING LEGAL EDUCATION
Sponsor Number: ________________
217 East Edenton Street, Raleigh, NC 27601
Course Number: _________________
Post Office Box 26148, Raleigh, NC 27611
SA _____ E _____ G _____ T _____
(919) 733-0123
BAR MEMBER’S APPLICATION FOR CLE CREDIT
SEE THE BACK OF THIS PAGE FOR SUMMARY OF NC REQUIREMENTS
Note:
This form should be used only when the sponsor of the CLE activity declines to submit an approval request. The
attorney should ask the sponsor to request approval before submitting this form and supporting documentation.
1.
Full Name of Attorney: ____________________________________________ Telephone (______)_____________________
2.
NC State Bar Membership Number: _________________________________ E-mail Address: ________________________
3.
Address: _____________________________________________________________________________________________
4.
Full Name of CLE Sponsor:______________________________________________________________________________
5.
Name of Sponsor Contact: ___________________________________________ Telephone (_____)____________________
6.
Title of CLE Activity: ____________________________________________________________________________________
7.
Exact Date(s) of CLE Activity: _____________________________________ Location (city, state): ______________________
8.
Registration Fee(s):____________________________________________________________________________________
9.
Type of Activity:
Interactive computer program (CD/Rom, Online, IPod or MP3)
(Describe the interactive component of the program)
10.
Live program, presenters and attendees on-site
Live audio-only (telephone) hook-up
Live audio and video
transmission, with/without Web cast
Group video viewing
/
11. This CLE activity
was
was not open to and advertised to attorneys outside my firm/company.
12. Member’s request for number of CLE minutes (for computer programs, give running time):
Ethics, professional responsibility, or professionalism:
____________
minutes
Substance Abuse/Mental Health Awareness (must be a minimum of 60 minutes)
____________
minutes
General/other
____________
minutes
(Substantive law topics other than ethics, professional responsibility, or professionalism)
Total:
____________
minutes
required
13. Attach the following
information:
a.
A description of the subject matter of the course.
For longer programs, provide a description of the subject matter covered in each section.
b.
If the program has an ethics, professional responsibility, professionalism or substance abuse
component, please submit the course materials.
c.
Identification of all presenters by name and qualification.
d.
A real-time agenda. (See back for time and content requirements.)
14. The Attorney represents that to his or her knowledge this CLE activity (A) Complies with the Rules and Regulations including
any amendments thereto (see ncbar.gov or the current North Carolina State Bar Lawyer’s Handbook), and (B) Was not
previously disapproved by the Board of Continuing Legal Education. The Attorney acknowledges that approval of this CLE
activity may be declined or revoked for violations of the aforesaid Rules and Regulations or for the failure of the Attorney to
comply with the agreements and representations in this request.
15. The Attorney acknowledges that he or she is responsible for submitting all related attendee fees for an approved course.
Date: ______________________________ Attorney’s Signature: ___________________________________________
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