Fillable Form 72201: ARKANSA 1. Title of S 501-682-9410 (Administrative Office of the Courts)

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Form 72201: ARKANSA 1. Title of S 501-682-9410 (Administrative Office of the Courts)

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Country of origin: US
File type: PDF

U.S.A. forms for Administrative Office of the Courts

BROWSE ADMINISTRATIVE OFFICE OF THE COURTS (AR) FORMS

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ARKANSA
S
ALTERNATIVE DISPUTE RESOLUTION COMMISSION
625 MARSHALL
DRIVE,
SUITE
1200
LITTLE ROCK,
AR
72201
Telephone: 501-682-9400
Facsimile:
501-682-9410
REQUEST
FOR CME
CREDIT
BY A
SPEAKER
(NOTE: MODERATORS WHO
DO NOT
CONTRIBUTE SUBSTANTIVE INSTRUCTION
MAY
NOT
RECEIVE ENHANCED
CREDIT
AS A
SPEAKER
).
1. Title of
program:
2.
Subject
of your
presentation:
3. Date(s) and
location(s)
upon which you
spoke:
( 1)
(2)
4. If your presentation
was as a solo
speaker
(not part of a panel), how long was your
presentation?
(rounded
to
nearest
1/4
hour)
5. If your presentation
was as a
member
of a panel, how long was the panel
presentation
in
its
entirety? (rounded
to
nearest
1/4
hour)
6. The
undersigned speaker
states that the
presentation(s)
noted above comply with the
Arkansas
Alternative Dispute Resolution Commission Continuing Mediation Education Requirements for
Certified Mediators
.
7.
Print name: Signature:
8. Tel. No. Certification No.
9.
Mailing
Address:
P.O.
Box or
Street
City State Zip
Code
CME4 (complete
reverse
side
)
click to sign
signature
click to edit
CERTIFICATE OF ATTENDANCE FOR
REMAINDER OF PROGRAM
In addition to the credit I am claiming for speaking at this program, I am entitled to claim
________ credit hour(s) for the remainder of the program. (Do not include the amount of time
claimed for your presentation.)
__________________________________________________
Signature
*******************************************************************************
TO BE COMPLETED BY SPONSOR
1. Sponsor ID#: _______________ Program ID#: _______________
2. The undersigned sponsor representative confirms the representations made by this speaker,
(only to the extent of the presentation) and further confirms that the presentation was in
compliance with the Arkansas Alternative Dispute Resolution Commission Continuing
Mediation Education Requirements for Certified Mediators.
3. Sponsor name: ______________________________________________
4. Sponsor representative: ________________________________________
________________________
Date
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signature
click to edit
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Form 72201: ARKANSA 1. Title of S 501-682-9410 (Administrative Office of the Courts)

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Completed 20 July 2020

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