CE Endorsement Application - National Association of Social Workers NC Chapter

CE Endorsement/Approval Application

UPON SUBMISSION OF THE FORM, YOU WILL BE REDIRECTED TO A PAYMENT SCREEN. APPLICATIONS THAT DO NOT HAVE AN ACCOMPANIED PAYMENT WILL NOT BE PROCESSED.

North Carolina Social Workers are only required to have contact hours, not the official CEU
Is this course for Approval or Endorsement? *	Approval (for recorded CE) Endorsement (for live CE courses)
First Name *
Last Name *
Email Address *
Organization *
Mailing Address *
City *
State *
Zip/Postal Code *
Phone *
Program Title *
Program Date *
Location *If in-person, put address. If virtual, write "virtual".
Is the facility ADA compliant? *	Yes No N/A
Number of CE hours requested *

Do you want this to be considered for Ethics CE? *For Ethics CE: Must be Ethics content related to social work practice and ethical decision-making	Yes No
How was the need for this program determined? *
Please describe how this program will help Social Workers serve their target population. *
Is a BSW, MSW, LCSW a presenter for this program *	Yes No
Is a BSW, MSW, LCSW a member of the planning committee for this program *	Yes No
If no, please list procedures used to ensure CE is representative of the social work perspective.
Please list an agenda including full learning objectives & start/end times, breaks, etc.
Please Attach Your Full Agenda Here: *
.

NASW-NC requires you to conduct an evaluation of your workshop that states the learning objectives.

List evaluation questions below. Questions MUST include learning objectives. *
Program Description *
Please list ALL Speakers below:

Speaker 1: Name, credentials, and expertise
Speaker 2: Name, credentials, and expertise
Speaker 3: Name, credentials, and expertise
Speaker 4: Name, credentials, and expertise
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UPON SUBMISSION OF THE FORM, YOU WILL BE REDIRECTED TO A PAYMENT SCREEN. APPLICATIONS THAT DO NOT HAVE AN ACCOMPANIED PAYMENT WILL NOT BE PROCESSED.