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Apply to Become a Registered Continuing Education Provider

Education Providers Online Application Form

Before you begin this application process, please print a copy of the Provider Manual and keep a copy for your records. This document will assist you in the application process and administrative procedures.

You will have 30 days to complete the application. After completing the application, you must mail in your application fee and supplemental materials within 15 days.

Click here for a detailed explanation of the application process.

If you have previously initiated an application, then simply login to continue.

Organization
Organization Details
Enter the specified information about your organization below.
Name of Organization: *
Description of Organization:
May include mission, purpose, and goals of your organization.
(100 Words or less) 		* 0 Words
Type of Provider : *
Web Address - Organization: *
Telephone: *
Fax:
Mailing Address of Organization
Street / PO Box: *
City: *
State: *
Zip Code: *
Country: *
Primary Contact in the Organization
Personal Details
Prefix:
First Name: *
Middle Name Initial:
Last Name: *
Suffix:
Title:
Email: *
Telephone 1:  *
Telephone 2:
Fax:
Mailing Address for Primary Contact Person
Use organization address?
*
Account Access
This username and password will be used to log back in.
Username:
Password: *
Confirm Password: *
Your password must be 8 to 30 characters long and include at least three of the following: an uppercase letter, a lowercase letter, a digit, and a special character.
Submit to Setup Your Account



All applicants will need to click a link in a confirmation email to verify their email address before being given access to the site.

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