For Office Use Only

Date Red’d: _______________________

Paid: ____________ Ck#: ____________

Approved: __________ # CEUs: _______

Provider #: ________________________

Nwsltr: __________ Web: ___________

_____ Category I ______ Category II

National Association of Social Workers

Vermont Chapter

P.O. Box 1348,

Montpelier, VT 05601-1348

Phone: (802) 223-1713 Fax: (802) 229-4318

E-mail: naswvt@naswvt.org

Web: www.naswvt.org

CONTINUING EDUCATION APPLICATION

Please complete the following for the course for which continuing education credit is requested.

Applications must be received at least 30 days prior to the date of presentation.

I. Applicant Information
1. Name of Organization
2. Contact								3. Title
4. Phone Number								5. E-mail
6. Fax
7. Mailing Address
8. Description of Organization and Mission
II. CE Program Information
1. Program Title
2. Date(s)
3. Location
4. Target Audience
5. Open to Public?			Yes No
6. Cost to participants?
7. Expected # of participants?
8. Are there any co-sponsors of program?			Yes (please list) No
9. Instructor Name(s)			Degree(s)			Current Position & Relevant Experience (attach resume or profile)
10. Program Description (Attach copy of brochure)
11. Program Objectives
12. Describe teaching methods utilized during program such as video, overhead, lecture, small group, discussion, etc.
13. Method of Evaluation? (Attach copy of evaluation form)
14. Program Schedule (Complete the schedule listing instructional hours and breaks. DO NOT include breaks and lunch in the calculation of instructional hours.) (Attach copy of program schedule)		Time start			Time end		Total time			Content Description
		Total Instructional Clock Hours
15. Number of CEUs Requested
16. Type of Program (see CEU NASW VT’s Procedures and Policies)				Category I – Formal Educational Activities Category II – Informal Educational Activities
17. Do you want the event listed in NASW VT’s newsletter and or on website?				Newsletter Yes No Website Yes No
18. Do you need a certificate of attendance from NASW VT?				Yes No
III. Required Attachments and Fees Checklist
	NASW VT Continuing Education Application complete with all attachments included
	Copy of program schedule outlining the sequence of topics and instructors during the training
	Copy of presenter resume or NASW VT presenter profile for each speaker
	Copy/draft of program brochure (if available)
	Copy of evaluation form
	Fee Payment							Rate			Sub-total
	Program Fee: 1-6 CEU program							$75.00
	Program Fee: 7-over CEU program							$125.00
								Total Fee Enclosed
IV. Continuing Education Participation Agreement Checklist As a provider of continuing education event with approval from NASW VT, I agree to (please initial next to each item):
	Submit a fully completed application with appropriate fee at least 30 days before the program.
	Present certificates of attendance to participants who complete the program. Certificates of attendance will include your NASW VT provider number for the training.
	Submit a completed participant list with names of all social workers requesting CEUs to NASW VT within 30 days of the program date.
	Ensure that attendees complete program evaluations.
	Make evaluation forms available to NASW VT upon request.
	I agree to all of the conditions stated in the NASW VT Policies and Procedures for continuing Education Approval.
Print Name									Title
Signature									Date
Send Completed Applications and ALL attachments along with fee to: NASW VT PO Box 1348 Montpelier, VT 05601-1348 Phone: 802-223-1713 Fax: (802) 229-4318 Email: naswvt@naswvt.org Applications may be completed online at www.naswvt.org.

CEU Application 01.08.02