ce approval form - pof chapter ce... · microsoft word - ce approval form.doc author: aabington...
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Authorized Signature of RegionalEducation Committee Chairperson
Professional Opticians of FloridaApplication for Approval of Continuing Education
This form must be completed and submitted to POF headquarters no later than sixty (60) days prior to the dateof the program in order for approval to be made. This form must be completed in its entirety or your coursewill not be approved.
__________ __________________________________Today’s Date Chapter Name Contact Person (*Florida Licensed Opticians only)
____________________ ____________________ _______________________________________Contact Phone Contact Fax Contact E-mail
________________________________________ ____________________ _____ _________Contact Street Address City State Zip Code
__________ ______________ _______________________________________________________ProgramDate Total Program Hours Facility Name
________________________________________ ____________________ _____ _________Facility Street Address City State Zip Code
Course Information
________________________________________________________________________________________Course Title (*Product brand names cannot be included in course titles.)
_____________________________________ ___ Outline attachedCourse Instructor (*Required)
CE Slips by Mail ____ E-mail (*Enter recipient’s address below.)Course Category (*Choose only one.) Qty.
__________________________________________________ ____________Course Length Starting Time
Forward this form, alongwith a course outline and speaker resume, to yourRegional Education Committee Chairpersonw:
George Sweat Gloria Dodge3020 Hartley Road, Suite 190 1300 S Tropical TrailJacksonville, FL 32257 Merritt Island, FL 32952904-292-0004 Phone 321-986-8554 Phone904-292-0005 Fax Fax Same
They will in turn approve and sign the form and return it to POF headquarters at:
Provider # B00007
JJJohn Girdler8705 Minnow Creek DriveTallahassee, FL [email protected]
50-1645
John Girdler8705 Minnow Creek DriveTallahassee, FL 32312850-264-6805 fax [email protected]
Submit 30 days in advance for approved speakers & courses
Submit 60 days in advance if a new speaker or new course topic
This form must be completed in its entirety for your course to be approved.
MM/DD/YYYY
(###) ###-#### (###) ###-#####
FL
MM/DD/YYYY
FL
POF • P.O. Box 1296 • Crawfordville, FL 32326 • Fax (850) 201-2947
Please fill out one form per course