Ncsb Form 4 - Accredited Sponsor'S Application For Cle Credit
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2NCSB Form 4 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: _________________
P.O. Box 26148, Raleigh, NC 27611
SA _____ E _____ G _____ T _____
(919) 733-0123
ACCREDITED SPONSOR’S APPLICATION FOR CLE CREDIT
Note: This application should be transmitted to the Board of Continuing Legal Education
at least 50 days prior to presentation of the CLE activity.
1.
Full Name of Sponsor:__________________________________________________________________________________
2.
Name of Contact Person: _________________________________ Telephone (______)______________________________
3.
Address _____________________________________________________________________________________________
4.
E-mail Address: __________________________________ Web Address: _________________________________________
5.
Title of CLE Activity: ____________________________________________________________________________________
Interactive computer program (CD/Rom, Online, IPod or MP3)
6.
Type of Activity:
(Describe the interactive component of the program)
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
If the activity is pre-recorded, please provide the date of original production: ________________________________________
7.
Date/Time of Live Activity: Begin (hour & date): ____________________ End (hour & date): _________________________
8.
Location (city, state/country):_____________________________________________________________________________
9.
Registration Fee (s):____________________________________________________________________________________
10. How is the CLE activity being offered and advertised (specify method and location of advertising) : ____________________
11. The CLE activity _____ was / ____ was not open to and advertised to attorneys outside of the firm/company.
12. Please attach the following required information:
A.
A description of the subject matter covered in the course. For longer programs, provide a description of the content of each section.
B.
If the program has an ethics, 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.)
13. Sponsor’s calculation of 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
14. The Sponsor agrees to furnish to the Board of Continuing Legal Education, within thirty (30) days after the CLE activity,
the following :
A.
An alphabetical list of attendees, including their NC State Bar membership numbers and a statement of the ethics, substance
abuse/mental health awareness, general and total credit hours taken by each attendee.
B.
The required sponsor fee computed at $3.50 x total approved CLE hours x total number of NC attendees.
(See back for fee information.)
15. The Sponsor acknowledges that the Board may independently determine the hours of CLE credit available for this activity and that any such
determination will be conclusive.
16.
The Sponsor acknowledges that this activity may be disapproved and its accredited sponsor status revoked for violations of the
Continuing Legal Education Rules and Regulations, or failure to comply with the agreements and affirmations contained on this form.
Date: ____________________________
Accredited CLE Sponsor: ______________________________________________
Signature: ___________________________________________________________
Title: _______________________________________________________________
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