Individual Activity Application - Review Fee Payment Form Updated

Date

MonthDayYear
Individual Activity Application Review Fee

Payment Form
Organization Name
Please list the name of the Activity Provider, as identified in the IEA Application
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Activity Title
Activity Date
Contact Name

First NameLast Name
Contact Title
Preferred Phone

Area CodePhone Number
Preferred E-mail
Previous Approval: Has your organization received approval from another ANCC Accredited Approver (e.g. another state nurses association) in the past 12 months?
Provide the name of the ANCC Accredited Approver (state nurses association) through which you sought approval.
Select a payment type
Hours
Total
Note: If your application cannot be processed for any reason after submission and payment is made, an administrative processing fee will be deducted from any eligible refunds.

Please make checks payable to:

VTL Solutions
217 Oscar Drive, Suite C
Jefferson City, MO 65101

Total You Pay

USDNote: If your application cannot be processed for any reason after submission and payment is made, an administrative processing fee will be deducted from any eligible refunds.

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Should be Empty:

Individual Activity Application Review Fee

Total You Pay