[current-page:query:date1] | [current-page:query:ce] contact hrs | [current-page:query:rx] pharmacology hrs*
[current-page:query:SKU] | [current-page:query:location] | $[current-page:query:fee] processing fee

DIRECTIONS: Submit this form to the course coordinator at the activity. Successful completion requires completion of all required activities and an evaluation. A link to your certificate will be emailed to you within four weeks.

PLEASE PRINT CLEARLY. ALL INFORMATION IS REQUIRED.

Name________________________________ Highest Degree__________ Mobile Phone____________________

Address (City, State, ZIP)____________________________ Agency Name _______________________________

Email Address____________________________Your Profession or Specialty _____________________________

ATTESTATION OF ATTENDANCE (Required for your certificate)

I successfully completed this activity and earned ________ contact hours. (Maximum you can claim is [current-page:query:ce].)

Date of Activity Completion_________ Location (City, State)_____________________________

Your Signature__________________________________ Date___________________________

*Pharmacology hours at the advanced practice level.

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