Fillable Arizona Department of Agriculture (Arizona)

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Arizona Department of Agriculture (Arizona)

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https://agriculture.az.gov
DOUGLAS A. DUCEY
Governor
MARK W. KILLIAN
Director
Arizona Department of Agriculture
Environmental Services Division & Pest Management Division
1688 W. Adams Street, Phoenix, Arizona 85007
(602) 542-4373
________________________________________________________________________________________________________________________
PMD / ESD Continuing Education Credit Request
Course Description:
Course Title ___________________________________________________________________________Course Date________________________
Course Location/Address __________________________________________________________ Start Time ___________End Time ____________
Sponsor/Organization Name ________________________________________________________________________________________________
Contact Person _________________________________________________________________________________Phone #___________________
Contact Person Address __________________________________________________________________________Fax #_____________________
Email Address________________________________________________________________Provider ID Number (REQUIRED)_______________
Course requested for: Environmental Services Division (Agricultural) Pest Management Division (Structural)
Number of CE Hours Requested____________
Course Availability (Please check all applicable boxes)
Open to the public Closed to the public Online
Attach to this request (check off items):
Course Outline indicating time period for each item covered. Description of the information that will be covered under each outline item.
Biography of each person who will present course information, demonstrating the person’s qualifications. The address to which course
material(s) must be sent if different than the sponsors address. If the course will be presented at more than one location, the address or each
location at which course information will be presented.
Acknowledgments:
CEU request(s) must be received by the Department at least fourteen (14) days prior to the course date. Failure to comply may result in the
delay or denial of your request.
Course sponsor acknowledges the following Arizona Department of Agriculture Environmental Services Division and/or Pest Management Division
policy guidelines and understands that Continuing Education Units granted by the Department may not be honored upon presentation by the course
attendee if these policy guidelines have not been followed. Sponsor agrees, at the beginning of each approved CEU course, to notify attendees of the
following policy guidelines.
NOTE: Arizona Department of Agriculture staff may attend, without cost or advance notice, to monitor this course for evaluation purposes.
If it is determined that the course or presenter varies significantly from that approved, the number of CEU’s may be modified or the course approval
may be revoked.
CEU Providers:
Structural Course sponsors must report the licensees CE hours to the ADA by using the online reporting tool within ten days of
the class.
Agriculture Course sponsors are encouraged to report class attendance electronically by utilizing the online reporting tool.
When using the online reporting tool you must keep a copy of the sign-in sheet with the name, license number and signature of
the attendee for a minimum of two years.
For Agriculture CE Providers that prefer to do things on paper with the old multi-copy CEU forms - see page 2.
I, the undersigned, acknowledge that I have read & understand the requirements for granting CEU’s to the attendees of this course: and I agree to
comply with the policy guidelines stated above.
Print Name_______________________________________ Signature___________________________________________ Date_______________
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https://agriculture.az.gov
PMD / ESD Continuing Education Credit Request
PAGE 2
For Agriculture CEU providers choosing to use paper versus the more efficient on-line tool for recording course attendance.
Number of AG CE forms requested,________________
For Agricultural ESD Licensees:
If reporting on paper triplicate CEU Forms:
Course attendees must sign in on the “Sign-in” form for each course granted CEU credit.
Course sponsor will supply ONE CEU form to each credentialed attendee.
Attendees with more than one credential must place each credential number in the appropriate box on the single form.
Course attendees must completely fill out and sign the CEU form for each course granted CEU credit and return the completed
forms to the course sponsor at the end of the approved course.
Course sponsor must sign each completed form, return the pink copy to the attendee, and advise the attendee to keep the pink
copy so when renewal time arrives, if there are any questions about course attendance the department can ask for a copy of the
form if needed.
Course sponsor must return the sign-in sheet(s), the completed white copy of the CEU forms, and all unused CEU forms to the
department within ten (10) working days after the approved course.
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Arizona Department of Agriculture (Arizona)

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Completed 20 July 2020

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