Attendee Name:___________________________________________________

 

Certification Number:_______________________________________________

 

Name of Course/Workshop/Program:__________________________________

 

Sponsoring Organization / Association / Agency:_________________________

 

Date(s) of Course/Workshop/Program was offered:_______________________

 

Instructor/Presenter/Facilitator:_______________________________________

 

Course Description (Fill-in here or attach documentation): ________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

 

 

Number of Contact Hours:  [      ]

 

I the undersigned confirm/verify that this attendee did complete this Course/Workshop/Program for the number of contact hours listed above and that this was an organized program of instruction.

 

 

__________________________________________              ________________

Signature of Presenter                                                                                 Date

 

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