Request for MWAMTA Approved-Provider CMTE Sponsorship

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If you are providing continuing education opportunities throughout the year (Regional Conference Excluded) and are interested in using the Midwestern Region's AP number to certify CMTE credits, please submit this form NO LATER THAN 60 DAYS PRIOR to the date of your event. Please email Kailey Campbell, MA, MT-BC, MWR Continuing Education Director, with any questions: kailey.mtbc@gmail.com

Date of Event *

YYYY

Number of CMTE Credits for Event (1 Credit per 50 minutes of instruction) *

Fulfills Ethics Requirement? *

Yes

Title of Event or Presentation *

Course Description (250 Words) *

Detailed Schedule of Event/Course (include breaks) *

Measurable Learning Objectives with corresponding Board Certification Domains (No more than 4) *

Prerequisites?

Style *

Workshop

Lecture

Panel/Round Table

Other:

Audience (Check all that apply) *

Students

New Professionals

Experienced Professionals

Required

Course Cost

Name, credentials, and short description of qualifications of each presenter *

Main Contact Name and Email *

I understand that myself or the organization hosting said course will be responsible for the $100 course fee due to MWR Treasurer following course approval *

Yes

I am sending the resumes or CVs of all presenters to kailey.mtbc@gmail.com *

Yes

Submit

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