Program Sponsor Application
Cover Page
Licensed Marriage & Family Therapists
Continuing Education Certification Program
Massachusetts & Rhode Island
List each enclosed application by start date and proposed number of contach hours. Circle the state(s) you want certification for. Enter the application fees and total due. Please submit your application package and fees with this as the first page. Use additional copies of this cover page as needed. See also: "Information for Sponsors" and "Application by Program Sponsor".
Sponsoring Organization: _____________________________________ Today’s Date: _________________
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Start Date |
State(s) |
Contact Hours |
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Massachusetts |
Rhode Island |
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1. _____________ |
MA / RI |
__________ |
____ ($15/$25/$35) |
____ ($15/$25/$35) |
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2. _____________ |
MA / RI |
__________ |
_______ ($15) |
_______ ($15) |
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3. _____________ |
MA / RI |
__________ |
_______ ($15) |
_______ ($15) |
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4. _____________ |
MA / RI |
__________ |
_______ ($15) |
_______ ($15) |
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5. _____________ |
MA / RI |
__________ |
_______ ($15) |
_______ ($15) |
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6. _____________ |
MA / RI |
__________ |
_______ ($15) |
_______ ($15) |
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7. _____________ |
MA / RI |
__________ |
_______ ($15) |
_______ ($15) |
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8. _____________ |
MA / RI |
__________ |
_______ ($15) |
_______ ($15) |
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9. _____________ |
MA / RI |
__________ |
_______ ($15) |
_______ ($15) |
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10._____________ |
MA / RI |
__________ |
_______ ($15) |
_______ ($15) |
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Cover Page # _____ of _____ |
Column Total |
$_________ |
$________ |
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Total fees for this page: |
$________ |
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Total fee enclosed (for all Cover Pages): |
$________ |
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Fees: |
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1. For the activity listed that offers the highest number of contact hours (for each state): |
2. All subsequent activities submitted in the same package: Any number of hours: $15.00 each |
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1.0 up to 4.0 hours: 4.5 up to 14.0 hours: 14.5 or more hours: |
$15.00 $ 25.00 $ 35.00 |
3. Add second state: 1st activity is $15/$25/$35. Additional activities, any number of hours: $15.00 each. |
Please make checks out to: "FDA/CE Certifications" (Institutional order forms accepted with 30 days net.)
Submit all materials to:
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Michael I. Vickers, PhD |
voice 508.877.3660 extension 6 |
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Continuing Education Administrator |
fax 508.872.6330 |
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Family Development Associates |
email: m-vickers@comcast.net |
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40 Speen St., #106 |
web page: www.mftce.com |
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Note: Lists of certified activities, application forms, CE regulations and LMFT license regulations can be found on our web site. |
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