Qme Form 118 - Application For Accreditation Or Re-Accreditation As Education Provider

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Administrative Director, Division of Workers' Compensation
ATTN.: Medical Unit
P. O. Box 71010
Oakland, CA 94612
APPLICATION FOR ACCREDITATION OR
RE-ACCREDITATION AS EDUCATION PROVIDER
FOR OFFICE USE ONLY
NO._______________
DATE_____________
APPROVED___________
DENIED______________
INITIALS__________
SECTION 1 – PROVIDER
NAME OF PROVIDER
ADDRESS
CITY
STATE
ZIP
DIRECTOR OF EDUCATION
PHONE
FAX
E-MAIL ADDRESS
TYPE OF ORGANIZATION
LENGTH OF TIME IN BUSINESS
DWC PROVIDER NO.
NATURE OF BUSINESS/MISSION STATEMENT
PAST CONTINUING EDUCATION PROGRAMS
ACCREDITING AGENCIES WHO HAVE APPROVED PAST PROGRAMS
QME Form 118 (rev. February 2009)
Page 1

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