CNE Application Form-Individual Activity

CNE Application - Individual Activity

Please complete the form below to submit your CNE Application
Full Name *

First Name Middle Name Last Name

Current Address

Company Name
Street Address
City	State / Province
Postal / Zip Code	Country

Email Address *
Phone Number

- Area Code Phone Number
IMPORTANT INFORMATION:

$60 per content hour for programs 0.5 – 10 content contact hours

If over 10 content contact hours, please contact education@ctnurses.org to determine your reduced fee.

6 weeks to 3 weeks prior to the presentation date - Additional fee

Expedient fee $200

3 weeks or less prior to the presentation date, will not be reviewed and contact hours will not be provided
Title of Activity *
Please type in title of activity submitted
Start date

- Month - Day Year
Upload CNE Application *

Upload a File

Cancel of

My Products

1-10 hrs $60 per contact hour $ 60.00

Quantity

.5 Contact hour price $30 $ 30.00

Expedient Fee $200 - less than six weeks $ 200.00

Total $ 0.00

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

If paying by check: Make check payable to CNA

If you prefer to pay by check, complete the information above and send form and payment to: CNA, 1224 Mill St., BLDG B, Suite 223, East Berlin, CT. 06023. If you are paying by credit card, fax form and payment to 203-238-3437

Questions? Phone: 203-238-1207 x1 or email virginia@ctnurses.org

Returned Check Policy:

An administrative fee of $15 will be charged for returned checks.
Should be Empty: