Assessment of Individual Activity Eligibility

Assessment of Individual Activity Eligibility

Chi Eta Phi Sorority, Inc.®
Name of Organization*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Organization Webpage (If Your Organization Does Not Have a Webpage, Please Put N/A)*
Name of Activity*
Date the Activity Will First Be Held or Available to Learners*

MonthDayYear
Date
On behalf ofOrganization Name*, I hereby attest the information provided on and with this application is true, complete, and correct. I further attest, by my signature below, that this applicant will comply with all eligibility requirements and approval criteria throughout the approval period, and that the applicant will notify Chi Eta Phi Sorority, Inc. ® promptly, if, for any reason, while this application is pending or during any approval period, the applicant does not maintain compliance. I understand any misstatement of material fact submitted on, with, or in furtherance of this application for activity approval shall be sufficient cause for Chi Eta Phi Sorority, Inc. ® to deny, suspend, or terminate approval of this activity and to take other appropriate action against this applicant.
I will retain all documents for this educational activity for a minimum of six (6) years in a safe and secure manner. The provider of this activity must keep a record of the number of contact hours earned by each participant and their unique identifier.

A typed name in the box below serves as the electronic signature of the individual completing this form and attests to the accuracy of the information given.
Completed by Nurse Planner and Credentials: Name & Credentials* Date: Date*
Should be Empty: