CBMT Approved Provider Five Year Application
Please refer to the CBMT Approved Provider Manual, Sixth Edition, to assist you in preparing this application. You can find this manual on the CBMT website at www.cbmt.org/approved_providers. The information you provide will be used to determine whether your organization continues to meet the criteria for approval. Incomplete applications will not be reviewed. Be specific, but brief. If you would like to request a mentor from the Continuing Education Committee to guide you through this process, or to request a payment plan, please contact the CBMT Continuing Education Coordinator, Hindi Burkett, MT-BC, at hburkett@cbmt.org or 1-800-765-2268 x2.

Please follow these instructions:

1. Complete and submit the Five Year Application below. An electronic copy will be emailed to you for your records.
2. Submit the $250 application fee to the CBMT office either by check or on the CBMT website under the “Products and Services” tab.

Email address *
Provider General Information
Name of Organization *
Name of Continuing Education Director *
Street Address, City, State, Zip: *
Phone Number(s) *
Website Address: *
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