COAHOMA COMMUNITY COLLEGE
EDUCATIONAL OUTREACH
PARTICIPANT APPLICATION FOR CEUs
In order to receive Continuing Education Unit for a program, this form must be completed by each participant and
submitted to the non-credit program instructor who will submit the form to the Office of Educational Outreach with
payment receipt.
Note:There is a two-week wait from the date of request
.
Name ________________________________________________________________________
Social Security Number _________________________________________________________
Address ______________________________________________________________________
City ________________________ State ___________________ Zip ___________________
Daytime Phone ____________________________ Evening Phone ______________________
E-mail Address ________________________________________________________________
Program Title _________________________________________________________________
Sponsoring Organization ________________________________________________________
Location _____________________________________________________________________
Date(s) _______________________________________________________________________
________________________________________ ________________________
Instructor’s Signature Date
The instructor’s signature verifies that the participant met the requirements to receive CEUs for the workshop indicated above.
3240 Friars Point Road, Clarksdale, MS 38614 Phone: 662-621-4127
PERSONAL INFORMATION
(PLEASE
ANSWER ALL QUESTIONS)
PROGRAM INFORMATION
click to sign
signature
click to edit
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