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NASW-Alabama Chapter

Continuing Education Unit (CEU) Program

Duplicate Contact Hour Certificate Request Form

 

(PLEASE PRINT CLEARLY ALL FIELDS REQUIRED)

 

Full Name (as Registered) ___________________________ ________________________________________

Mailing Address ___________________________________________________________________________

City _________________________________________ State _______________ Zip Code _______________

Preferred Contact Phone (        )_______-_________ Email Address: _______________________________

 

WORKSHOP OR CONFERENCE INFORMATION (NOTE:  One Form Required per Item Requested):

Title: ____________________________________________________________________________________

Date Attended:___________________________Location:_________________________________________

Presenter(s) / Facilitator(s):  _________________________________________________________________

Duplicate Certificate Cost: $25.00 per Item Requested For Verification

TOTAL COST $______

Payment Method (Mark Appropriate Method): CHECK ENCLOSED: # ________ INVOICE:_________

Email Address to Route Invoice: _____________________________________________________________

Signature: ________________________________________________________________________________

RETURN FORM TO:

NASW – Alabama Chapter, P.O Box 231366 Montgomery, AL 36123

OR

Email: Alabama@naswal.net

For Office Use Only:

Attendance Roster VerifiedYES______ NO______ Date Verified:_________________________________

Replacement Contact Form IssuedYES______ NO______ Date Issued:____________________________

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