OSBLSW Form 504 Revised 06/2012 Page 1 of 1
VERIFICATION OF ATTENDANCE*
For Continuing Education Hours
(Include City, State, Zip)
Name of Event
Clinical Social Work Practice
Number of Clock Hours
Social Work Administration
Number of Clock Hours approved for E
* THIS FORM MAY BE REPRODUCED.
If this form is submitted for an event that HAS NOT been previously approved by the Board at the request of the sponsoring
organization, event information and a Continuing Education Approval Category I and II or Continuing Education Approval Category III
form must accompany this form. This request may be submitted at any time during the calendar year the event occurred.
If this form is submitted for an event that HAS been previously approved by the board at the request of the sponsoring organization, no
other documentation is necessary. In this case, please hold this form and submit if audited.
Please provide CEP Number:
OKLAHOMA STATE BOARD OF LICENSED SOCIAL WORKERS
PO Box 18817 Oklahoma City, OK 73154
Phone 405-521-3712 Fax 405-521-3713
WEB www.ok.gov/socialworkers E-Mail firstname.lastname@example.org