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ONLINE Course Submission Form For Live Seminars And Workshops

Provider Name
Provider Number
Provider Number Expiration Date (MM/DD/YY)
E-mail Address
Course Name
Course Category (scroll to view list)
Continuing Education Hours (Must not exceed 50 hours)


Answer Each Item Below (IF APPLICABLE):
	Yes	No	This course is being co-sponsored with another NCBTMB Approved Provider? If YES, answer the next item.

Co-providership with Another NCBTMB Approved Provider (Record Keeping, Marketing, Promotional Responsibility) I agree to identify which party will be responsible for certificates, transcripts, marketing, promotional, and venue (per the NCBTMB guidelines) and to keep on file the co-providership agreement form for this course. Forms will be presented only upon request to the NCBTMB. (To access forms, go to CE Providers).
Yes, I Agree
Not Applicable

Providing Teaching Assistants Our organization agrees to provide any contracted NCBTMB Traveling Provider access to qualified teaching assistants as needed. We further agree to maintain a list of assistants and will maintain a biographical form for each assistant. (To access forms, go to CE Providers).
Yes, I Agree
Not Applicable

I agree to keep on file biographical forms for all qualified teachers. These forms will be requested within the next renewal application. If audited during your in-cycle period, you may be requested to provide this biographical form to NCBTMB.
Yes, I Agree
Not Applicable

Traveling NCBTMB Approved Providers (Record Keeping, Marketing, Promotional Responsibility) I am an individual provider and travel to different sites. I agree to take full responsibility for record keeping, certificates, evaluations, transcripts, marketing and promotional materials, and venue per the NCBTMB guidelines and to keep on file a list of all the locations and dates where this continuing education course will be offered. I will make this list available only upon request to the NCBTMB.
Yes, I Agree
Not Applicable

Use of Teaching Assistants As a traveling provider, I agree to include in my contract access to qualified teaching assistants (as needed) when co-sponsoring with an NCBTMB Approved Provider registered as an organization. This ONLY APPLIES to contractual agreements with an NCBTMB Approved Provider that are (a) an organization and (b) have qualified teaching assistants.
Yes, I Agree
Not Applicable

Course Description (50-100 words) MUST NOT EXCEED 100 WORDS. Your course description must include: A summary of the course The appropriate number of measurable learning outcomes (See Approved Provider Reference Guide, Section 3 for more information on measurable learning outcomes).

Course Instructor’s Name:

Our organization agrees to keep on file biographical forms for this qualified instructor. This form will be requested within the next renewal application. If audited during your in-cycle period, you may be requested to provide this biographical form to NCBTMB. (To access forms, go to CE Providers).
Yes, I Agree
Not Applicable

Description of Instructor’s qualifications to teach the continuing education course submitted. (50-100 words) MUST NOT EXCEED 100 WORDS

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