CE Request for Approval

The following information must be submitted to the Board prior to the date the course is offered.

See rule R4-21-210 for complete information on continuing education and approval.

First Name

Last Name

Email

Address

City/Town

State/Province

ZIP/Postal Code

Phone

Program Information

Time and Place of Program

Course Name and Location

Address

City/Town

State/Province

ZIP/Postal Code

Conditions of Availability (How will you notify all optometrists?)

Contact Person

Total Number of CE hours requesting. Please indicate the number of Regular, Practice Management or self-instructed (online or webinar) CE’s

Instructor’s Name – Must attach CV’s

Program Content

Please provide a DETAILED description of the program content - syllabus,course description, notes etc in a .pdf format.
Unlimited number of files can be uploaded to this field.
100 MB limit.
Allowed types: pdf.

Additional Files

Unlimited number of files can be uploaded to this field.
100 MB limit.
Allowed types: pdf.

I agree - I understand that by signing, my electronic signature is the legal equivalent of my handwritten signature and I consent to be legally bound to this agreement. I further agree my signature on this document is as valid as if I signed the document in writing. Under penalty of perjury, I herewith affirm that my electronic signature was signed by myself with my full knowledge and consent.

Signature

Sign above