Continuing Education Units Program Application

Professional Development

Continuing Education Units Program Application

If you would like to offer �� continuing education units for your program, you must complete an application using the form below. Please avoid using previously downloaded copies of the application. Applications must be submitted at least 35 days before the start of your program to allow time for processing.

Program details

Title (how the program will be identified and promoted) (required)

Format (required)

Blended/Hybrid: Program is a combination of face-to-face and virtual/online

Face-to-Face: Participants physically attend entire program

Virtual/Online: Entire program through some type of virtual/online media

Online registration link if needed

Target audience (example: child care professionals, certified firefighters, etc...) (required)

Participant fee (required payment to participate in this program) (required)

Your Company/Organization

Company/Organization Name (required)

Address Line 1 (required)

Address Line 2 (required)

City (required)

State (required)

Zipcode

Event Location

Same as Organization Address

Building

Address Line 1

Address Line 2

City

State

Zipcode

Total contact hours (required)

The actual time used for instruction. Do not count the welcome, breaks, lunch, dinner speeches, homework, preparation time, registration, or similar non-instructional activities.

�� CEUs requested (1 CEU = 10 contact hours, cannot be less than 0.3) (required)

This program can be offered up to six (6) times before a new application will need to be submitted. Provide start and end dates for up to six offerings, within one calendar year.

Number of Offerings (required)

Offering 1

Start date (required)

End date (required)

Offering 2

Start date

End date

Offering 3

Start date

End date

Offering 4

Start date

End date

Offering 5

Start date

End date

Offering 6

Start date

End date

Narrative (include basic information to let participant know what the program is about) (required)

Program descriptor (required)

Secondary program descriptor

What are the learning outcomes and objectives for this program? (required)

Outcome statements typically specify the knowledge, skills, or attitudes learners will acquire and be able to demonstrate during or following the learning experience. Learners should be aware of these intended learning outcomes prior to and during the activity.

Please attach a complete and final agenda to this application

The agenda must show specific training subjects. It must also include break times (10-15 minutes for every 2.5 hours of instruction) and meal breaks (full day sessions should include a 30-60 minute lunch period). Any agenda or program changes must be approved by �� before the first day of the program via written request.

Please Note: Agendas must reflect the number of hours indicated for the program, excluding breaks. Once the program is approved, you and/or your presenter must run the program according to the final agenda submitted with this application. This means there can be no changes to the program agenda. As an example, a presenter or administrator cannot:

Skip breaks to allow early release.
Shorten the lunch break to allow early release.
Change the start time.
Make the end time earlier (if you run over that’s okay)
Changing program dates without prior approval from �� Professional Development & Lifelong Learning.

One file only.
2 MB limit.
Allowed types: pdf, doc, docx, ppt, pptx, xls, xlsx.

Planning Representatives (what individuals or institutions have assisted in the creation of the instructional content) (required)

Instructor information

Please concisely list expertise and qualifications related to the program or training (required)

Please attach a resume or CV for each instructor detailing the qualifications and experience relevant to the program (up to 3 files)

Résumé or CV 1 (required)

One file only.
3 MB limit.
Allowed types: pdf, doc, docx, ppt, pptx, xls, xlsx.

Résumé or CV 2

One file only.
3 MB limit.
Allowed types: pdf, doc, docx, ppt, pptx, xls, xlsx.

Résumé or CV 3

One file only.
3 MB limit.
Allowed types: pdf, doc, docx, ppt, pptx, xls, xlsx.

Program Administrator Information

The Program Administrator is the individual completing the application and is the responsible party for verification of attendance and logistics

Name (required)

Affiliation (company name) (required)

Phone (required)

Email (required)

I acknowledge there is a $35 fee due with this application.

Payment Method (required)

Credit Card

��-Internal using FCC/JES

Mail a Check

*Please note: Credit card transactions can no longer be processed over the phone. We apologize for any inconvenience.

IMPORTANT: After clicking the yellow Pay Now button, you must click the green Submit button below in order to ensure that your application is submitted along with your payment. The yellow Pay Now button is for submitting payment only. Your full application is submitted by clicking the green Submit button on this page.

�� program FCC for JES (required)

Checks should be made payable to: �� Michigan University

Please mail a check with your total amount due within 7 days of this application to:

�� Michigan University
1905 W Michigan Ave
c/o Carol Bale
3245 Ellsworth Hall
Kalamazoo MI 49008-5230 USA

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Professional Development

Continuing Education Units Program Application

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