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Continuing Education Providers

APPLICATION FOR CONTINUING EDUCATION PROVIDERS

Note: For your convenience, you may complete and submit this form online *OR* you may print this page, complete the form manually and fax to 703/442-0630. This is a very complex form, please review carefully BEFORE you begin your submission.

Click here to download the Continuing Education Providers Handbook. (116K Adobe Acrobat File)

Check here if you are completing this form for the first time.
Check here if you are revising or adding new program information.

Date
Name of Provider
Address
City
State
Zip
Phone
Fax
Email

Individual responsible for completing this application:
Name
Title
Phone
Fax
Email

Indicate Status of Provider:

Providers will be classified according to category and will be charged a one time fee according to their provider category.
The rate is per credit hour:

Non-profit Training Provider, Trade Association (not an NGA Chapter)/Educational Institution $50.00
NGA Chapter No Charge
Training Provider $200.00
Product or Services Vendor $200.00
Government Agency No Charge

*Please note: If you are not a NGA Chapter or Government Agency, credit card fields are required to submit form electronically.
* Visa MasterCard American Express
* Name on Card
* Credit Card Number
* Expiration Date
* Total Amount Charged

Program Title/Topic
Date(s)
Location(s)
Program Length
Total Number of CCs
Check One: Ongoing Program One-time Program
   
Program Type:
Check all that apply: Lecture Demonstration Hands-on Training
Other (Specify)

Program Description:
Learning Outcomes: Each program must include at least one performance-based learning outcome that fulfills a required category.
For category topics refer to NGA's Continuing Education Providers Handbook. (116K Adobe Acrobat File)

Category Topic(s)


Learning Outcome(s) (Performance-based)
(What task/activity will the attendee be able to do as a result of the presentation?)


Program Outline
Please provide a detailed outline of your program in the space below.


Evaluation Method
Check all that apply:
Quiz/Test Q&A/Discussion Observation Other (Specify)

I certify that this information is true and correct. (Print name and date)

Training Aids
Check all that apply:
PowerPoint Presentation
Demonstration Materials (Specify)
Handouts (Specify)
Other (Specify)

Resources/References
Please list the resources or references you consulted or used to develop this program (i.e., subject matter experts,
reference manual or journal article, product samples, and so forth).

Please submit this form to NGA's Professional Development Department for review at least 30 days prior to program presentation.
If you have questions please email cert@glass.org or call 866/DIAL NGA, ext. 138.

Click here for the Program Reviewer Checklist.

 

 




 
 
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