Continuing Education Program CEU Program/Activity Application

Instructions

Complete each item on the form
Submit at least 30 days prior to planned program/activity
Send vitae via email attachment to knstevenson@mail.ecsu.edu for each instructor.

School

Department

Program/Activity Sponsor

First Name

Last Name

Phone Number

Email Address

Program/Activity Title

Course number

Course section

Program/Activity Start Date

Program/Activity End Date

Location of Activity

Program/Activity Format

Description of Activity

Evaluation Procedure

Anticipated Attendance

Program/Activity Contact Hours

CEU's Requested (1 CEU is awarded for each 10 contact hours of participation)

Comments

The Program/Activity Form will be sent electronically via email to your Dean for Approval upon your submission of this form.