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CE Submission Form
Please complete all of the following questions completely to have your CE uploaded.
*
1.
CE RECIPIENT
Full Name
(Required.)
*
2.
DATE STARTED
Use 3/1/2025 format
(Required.)
3.
DATE EARNED
Use 3/1/2025 format
4.
DATE EXPIRES
Use for CPR and other CE that expires
5.
CE TYPE
Ex. Regular, Infection Control, Ethics, or Lecture
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6.
CE HOURS
Number of Hours
(Required.)
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7.
ORGANIZATION
Name of organization providing CE
(Required.)
*
8.
SPEAKER
Use speaker or instructor's full name
(Required.)
*
9.
COURSE TITLE
Include the full course title with description
(Required.)
*
10.
ATTESTATION
(Required.)
I pledge on my honor that I have completed the number of continuing education hours for the course noted above and that the information submitted on this form is accurate and truthful.