PROGRAM APPROVAL FORM FOR AWARDING CEUs
In order to receive Continuing Education Units for a program, this form must be completed and submitted to the Office of
Educational Outreach two weeks prior to the beginning of the session.
Note: Please inform participants that there is a two-week wait for certificates.
PROGRAM INFORMATION
Program Title _________________________________________________________________
Instructor _____________________________________________________________________
Location _____________________________________________________________________
Number of Instructional Contact Hours _________ Number of CEUs _____________
Date(s) of Workshop_____________________________________________________________
Time(s) of Workshop____________________________________________________________
Is this workshop/program open to the public? Ο Yes Ο No
Please identify group being served _________________________________________________
Projected Number of Participants
__________________________________________________
CONTACT PERSON
Contact Person _________________________________________________________________
Sponsoring Organization or Department ____________________________________________
Address ______________________________________________________________________
Phone ________________________________________________________________________
E-Mail Address
_________________________________________________________________
__________ Approved __________Disapproved
_____________________________
DATE
_______________________________________
DATE
____________________________________
DIRECTOR OF EDUCATIONAL OUTREACH
________________________________________________
DEAN OF ACADEMIC AFFAIRS
CHIEF ACADEMIC OFFICER
3240 Friars Point Road, Clarksdale, MS 38614 Phone: 662-621-4127
COAHOMA COMMUNITY COLLEGE
EDUCATIONAL OUTREACH
