Application to be Granted
Continuing Education Credit |
||
|---|---|---|
Use this form to apply for CE credit for activities you already attended, that were not pre-certified by the Mass. Association for Marriage & Family Therapy, Inc. Make as many copies of this form as you need. Use one copy for each activity you attended. See check list at bottom. |
||
Name: |
______________________________________ |
Degree____ License # ____ State ___ |
Home address: |
______________________________________ |
|
______________________________________ |
City ________________ State _____ Zip _______ |
|
Telephone#'s: |
(w) _________________________ |
(cell) ________________________________ |
email: |
____________________________________________________________________________ |
|
Activity Title: |
|
|
Date(s): |
Start Date: ________ End Date: ________ |
CE hours granted: ___________ |
Sponsoring Organization: __________________________________________________________________ |
||
Address: |
____________________________________________________________________________ |
|
City: |
___________________________________ |
State____ Zip ________ Country _____________ |
Primary Instructor: _________________________________ |
Degree or Qualification: ____________________ |
|
____ LMFT ____Other mental health license + 2 years experience |
||
Activity Qualification: ___ Ethics & Legal ___ Clinical MFT ___ MFT Theory ___ Research |
||
___ Supervision & Training ___ Other relevant clinical (explain) _________________________ |
||
Enclosed verification of attendance (copies, not originals): |
____ certificate from program sponsor |
|
____ certificate from another mental health profession ____ hand outs or notes I took during the CE activity |
||
____ Instructor's request for CE credit: I was the instructor for the above described activity, and request CE credit for my participation. I understand that I can not count more than 15 hours of instruction per renewal cycle. |
||
Attestation: All of the above statements are correct and have been personally verified by me to the extent possible. I understand that this CE certification may become invalid as a result of any false or inaccurate information I may have provided. |
||
| Signature _____________________________________ Date ________________ |
||
Enclosures required: _____ $20.00 application fee for current renewal cycle ____ stamped, self-addressed envelope |
||
___ verification of attendance |
||
Submit this application to: |
||