This form has been created to allow Staff, Committees, DPGs and MIGs the opportunity to submit FNCE® 2017 events for review and approval of CPEUs.  

Guidelines:
-  This online form is intended for FNCE® 2017 programs requesting continuing education for events outside of the general educational program 
-  All submissions must be completed electronically
-  All submissions must be received 4-6 weeks prior to event to allow for processing prior to event

The contact information provided on this form will be used by the Lifelong Learning staff team for additional follow up and distribution of the approval certificate for use at the meeting. Additional information to support the approval of the program may be requested by the Lifelong Learning team.  

Any questions should be directed to Lori Granich (lgranich@eatright.org) at extension 4895.

* 1. Please provide the following contact information for this event:

* 2. Program/Event Title:

* 3. Program Duration:

Start Date and Time
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:
End Date and Time
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:

* 4. Program Type:  (Select all that apply)

* 5. Program/Event Description:

* 6. Program/Event Learning Objectives:
"By the end of this program, the participant should be able to..."

* 7. CPE Hours Requested:
*All CPE eligible activities must be at least 60 minutes to qualify for credit (1.0 CPEU). After one hour, CPE credit is calculated in 30 minute (0.5 hour) increments. No programs will be approved at 30 minutes (0.5 CPEU).

* 8. CPE Program Level:

* 11. Please provide the following information (Speaker #1):

* 12. Please provide the following information (Speaker #2, if applicable):

* 13. Please provide the following information (Speaker #3, if applicable):

* 14. Who is the target audience for this program?

* 15. Please use this space if you need to provide any additional information for the Academy Lifelong Learning team. For example:
- Additional speaker details
- Program Outline/Agenda

* 16. Is this event sponsored?

* 17. If yes, who is the sponsor?

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