PLM Provider Class Request Form

EVENT NAME
EVENT DATE

MonthDayYear
START TIME
END TIME
EVENT ADDRESS
CONTACT
PHONE NUMBER
Format: (000) 000-0000.
EMAIL ADDRESS
Is this a Public Event
Should Event Be Published on the AFA Calendar
Type of Event
PLM CREDIT HOURS REQUESTED
ATTACH COMPLETE AGENDA WITH ALL OF THE FOLLOWING ITEMS:

• EVENT NAME
• EVENT DATE
• EVENT START AND END TIME
• NAMES AND TITLES OF ALL SPEAKERS
• PRESENTATION START/END TIMES
• PRESENTATION TITLE AND BRIEF DESCRIPTION OF CONTENT TO BE COVERED
• FOR FIELD TRIPS/FIELD EVENTS, PLEASE INCLUDE TRAVEL TIME AND TIME AT
EACH LOCATION
Upload Event Agenda (PDF preferred)

Cancelof
PROVIDERS AGREEMENT
First Name Last Name (Providers Name), I agree that I will not submit any person as having attended a class that was not a verified attendee.
Providers Signature
Should be Empty: