Appendix 22 Member CEC Course Evaluation Form

Appendix 22 Member CEC Course Evaluation Form
Member Name*
Member Number*
Email*
example@example.com
If you have completed the course being assessed, please upload your certificate here.

Cancelof
Course Name*
Name of Instructor/Institution*
Course Date(s)

MonthDayYear
Date
Course Location(s)
Total Hours of Course*
*including all theory & practical hours*
Course Provider Email Address*
example@example.com
Website Address*
Course Provider Telephone Number
Course Provider Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DISCLAIMER - Should the Association (CMMOTA) choose to recognize this course as value for continuing education credits, it does not mean that any professional liability insurance provider will recognize the course as substantive for providing coverage for the practice of a modality or technique which may be attained within the training received. Further, the Association (CMMOTA) shall hold no responsibility nor liability for the content or accuracy of information which may be presented through this continuing education course, nor is approval of continuing education credits to be taken as an endorsement of the continuing education course, nor does any material presented through the continuing education course necessarily represent the views, values, or mission of the Association

Appendix 22 - Member CEC Course Evaluation Form © 2023 CMMOTA, All Rights Reserved.
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