Continuing education program

Initial Application Renewal Program Change CE PROVIDER FEES: Agencies of Government, Hospitals, and Community Colleges $1,000.00 Private Programs $2,000.00 CE PROVIDER NAME: PROVIDER LOCATION (County of primary headquarters): MAILING ADDRESS: ____ Street City State Zip PHONE NUMBER: FAX NUMBER: PROGRAM DIRECTOR: CLINICAL DIRECTOR: TYPE OF AGENCY (Check One): PREHOSPITAL SERVICE PROVIDER AGENCY BASE HOSPITAL OTHER HOSPITAL EMT TRAINING PROGRAM EMT-P TRAINING PROGRAM OTHER SCHOOL INDIVIDUAL OTHER: ESTIMATED NUMBER OF CE COURSES TO BE OFFERED PER YEAR: