LARA/BPL-003 (05/18)
SECTION III - Select the profession to which your program pertains.
Page 2 of 2
APPLICANT
Please Check
ELEMENTS TO BE INCLUDED WITH APPLICATION
1) This continuing education course is a planned learning program designed to promote the continual development
of knowledge, skills and attitudes on the part of the licensee.
OUTLINE (rationale, objective, goal, schedule, content )- Include an explanation of how the program is designed to
further educate the licensee, the topics and name of the speaker of each topic. The times of the specific topics and
breaks must be indicated on the outline.
RESUME for each speaker/instructor (limited to two pages per speaker) A copy of the instructional objectives which
have been developed for this program.
DESCRIPTION for the delivery method or methods to be used and the techniques that will be employed to assure
active participation.
2) This continuing education course has responsible sponsorship and capable direction including administrative
support which assures maintenance and availability of adequate records of participation as well as adequate budget
and instructional resources.
A brief description of the sponsoring organization.
The name, title, and address of the program director and a description of his/her qualifications to direct this program.
A description of how participants will be notified that CE credit has been earned. Include a copy of the certificate or
other document that will be issued.
A description of the physical facilities available to assure a proper learning environment.
A description of how attendance is monitored, sample documents, and the name of the person monitoring
attendance.
Please indicate how attendance is monitored by including sample documents and the name of the person monitoring
the attendance. The Board wants assurance that the attendees are checked out when leaving and checked back in
when returning. These times should be verified by the person monitoring attendance. This procedure should include
times in which the attendees leave one topic and go to another topic, within the same program.
CERTIFICATION
I hereby certify that the statements made in this application are true, complete and correct, and the materials submitted accurately
reflect the presentation and administration of this continuing education program.
If this is not signed and dated, your application will not be complete.
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Signature Title
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Type or Print Name Date
