CPEI Affiliate Organization Application

CPEI Affiliate Organization Application
Date Of Application

Month Day Year
Date
Your Name: *

First Name Last Name
Name of Affiliate (Training) Organization *
My Affiliate Organization: (Check Below) *
Address of Affiliate Organization *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Name Of CPE Supervisor: *

First Name Last Name
Phone Number: *
E-mail Address *
example@example.com
Website Address:
Additional Comments
ATTN: Once your application has been received and reviewed for approval, the NEW Memorandum of Understanding for CPEI Affiliate Organizations will be provided.

Beginning January 1, 2023, all CPEI Affiliate Organizations must submit the MOU. Annual Fees:
- CPEI Affiliate Organizations with a budget of less than $500,000 the annual fee is $750.
- CPEI Affiliate Organizations with a budget of more than $500,000 the annual fee is $1500.00
The new MOUs must be submitted No Later Than December 31, 2022 with payments.

My Products

Application Fee

$ 149.00

Total

$ 0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

CPEI Mailing Address: P. O. Box 9166, Fleming Island, FL 32006
Should be Empty: