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11th Annual Tribal Healing to Wellness Court Virtual Training (June 21 - June 25, 2021)
Application Form - Continuing Education (CE) Credits
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Name (Last, First) *
Address (Street or PO Box/ City / State / Zip) *
Email Address *
Telephone (Ex: 505-123-4567) *
License Number *
State *
Request for Continuing Education Credit - I request continuing education credit verification in the professional disciplines of: *
Check Dates Attending
Signature / Date (Ex: Keres Sarracino / 06.25.2021) - I hereby make an application for continuing education credit. I understand that to be eligible for continuing education credit, I must comply with sign-in verification requirements, complete an evaluation for each session I attend, and complete a Daily Attendance Log of sessions attended. *
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