OSBLSW Form 504 Revised 06/2012 Page 1 of 1
VERIFICATION OF ATTENDANCE*
For Continuing Education Hours
Home Address
Agency Address
(Include City, State, Zip)
Home Telephone
Agency Telephone
Name of Event
Sponsor Address
Sponsor Telephone
Sponsor E-Mail
Clinical Social Work Practice
Number of Clock Hours
Attended:
Social Work Administration
Number of Clock Hours approved for E
THICS
EQUIREMENT
* 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 james.marks@oswb.ok.gov
