ASHA CEU Participant Form
American Speech-Language-Hearing Association
Continuing Education Registry
Provider Code Course Number
ame ____________________________________________
Address __________________________________________
City ________________________________ State _______
Zip _______________ Country ______________________
Daytime Phone (_____)______________________________
E-mail Address ____________________________________
(Include Area Code)
Please enter your last name (as it appears on your
SHA id card) below. Enter the letters in the
spaces provided in the 1st row and fill the entire box that corresponds to the letter in each column.
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To update your address or phone number, or to obtain
your ASHA Account Number call ACTION CENTER
at 1-800-498-2071 between 8:30am and 5:00pm. E.T.
You must provide your ASHA Account Number.
ASHA Account Number
Provider Use Only
Complete only for those participants receiving less
than the maximum number of ASHA CEUs (i.e.,
partial credit). Please fill in leading zeros followed by
the number of ASHA CEUs. For example, to indicate a
participant earned .55 ASHA CEU's (that is, 5 1/2
hours) write 0055.
Revised 8/2011
Completion Date
Submit this form to the Provider at the end of the course if you wish to earn and maintain
ASHA CEUs through the ASHA CE Registry (annual fee required).
If not an ASHA member or CCC holder, you must be licensed or credentialed to practice
speech-language pathology (SLP) or audiology or preparing to practice to earn ASHA CEUs.
Licensed: _______________________________________________________
Certified: _______________________________________________________
Clinical Fellow: __________________________________________________
Enrolled in a graduate
program in SLP or audiology: _______________________________________
(University name and expected graduation date)
(Supervisor name and her/his ASHA account number)
(State/Organization and #)
(State and License #)
62046
