CEU Sponsor / Provider Application - There are two parts to this application. Part I - Sponsor / Provider Information and Part II - Course Information
PART I - Sponsor / Provider Information
Sponsor / Provider Name
Course Type
Please Select
Live
Online
Webinar
Mail
Other
Address
Unit/Suite #
City
State
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
E-mail
Telephone XXX-XXX-XXXX
Alternate Telephone XXX-XXX-XXXX
Website
APTA Member
Please Select
NO
YES - PT
YES - PTA
If Yes, Member #
CA PT/PTA License?
Please Select
No
YES - PT
YES - PTA
If YES, CA License #
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PART II - Course Information
Course Title
Instructor's Name
Number of CEUs Requested (One Hour = 0.1 CEU)
Course Date #1
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Location for Date 1
Course Date #2
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Location Date 2
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Location Date 3
Course Date #4
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Location Date 4
Course Date #5
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Location Date 5
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Upload File 3
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Upload File 4
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Upload File 5
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Name of Person Completing Applicaiton
Submission Date
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Day
Year
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