Please provide the information below to consider your request for awarding CEUs.  

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* 1. Request initiation date

Date
Time

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* 2. Requestor Contact Information

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* 3. Trainer(s) name(s)

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* 4. Trainer(s) Qualifications (title, education, experiences)

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* 5. Course Title

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* 6. Course Description

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* 7. Course Length (3 hours, 1-day, etc.)

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* 8. Training Location

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* 9. Training Date(s)

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* 10. Training Start and End Times

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* 11. List the Benefits for Staff Taking the Course

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* 12. List or Attach Curriculum Assets (materials)

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* 13. Maximum Number of Attendees Expected

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* 14. List or Attach Evaluation Plan

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* 15. List or Attach Course Learning Objectives

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* 17. Number of CEUs Requested

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* 19. Learning and Development Manager, Curriculum Signature

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* 20. Signature Date

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