Canadian Certified Crop Advisor Association

Feb 06, 2012

CEU Application Form

Continuing Education Units (CEU’s) for Canadian Certified Crop Advisor Association Training
Please apply for ONLY ONE activity per form and carefully print or type all requested information.

Required Field

Contact name:

Contact phone no.:

Contact fax no.:

Sponsoring organization:

E-mail address:

Contact address:

City:

Postal Code:

Program/Activity Title:

Target audience:

Open to the public:

Yes

Fee: $

Will this program offer an opportunity for participant evaluation of content?:

Yes

All fields are required in the panel below

Program/Activity Location(s) (Hotel, College, Research Centre, etc.)	Address	City / Postal Code	Date(s) (e.g. 10/16/2007)	Start Time (e.g. 06:00)	Finish Time (e.g. 18:00)

Program Information: Please complete page 2 of this form, listing each session topic. Also include a copy of the program agenda. Note that all trainings/programs should include an end-user evaluation, to be indicated on the course agenda.

CEU’s Requested (Please enter zero hours if no CEU’s requested for a particular category.)

Nutrient Management:	hours	Integrated Pest Management:	hours
Soil & Water Quality:	hours	Crop Management:	hours
Professional Development:	hours	Total:	hours

CCA Board Use Only

Course Code:

SWQ

IPM

Total

CCA Board rep Signature:

Date:

Note: Please use the Standards Document for Continuing Education to relate the training topics to the educational area.

All fields are required in the panel below

Date	Time (e.g. 06:00)	Session Topic	Educational Area (NM, SWQ, IPM, CM, PD)	Subject Matter Area # (Please use this document to relate Subject Matter Area to Educational Area)	Time requested (minutes)	Speaker name (provide credentials & qualifications on separate sheet)	Comments(for use by CEU Committee)

Return to: Ontario CEU Committee c/o Susan Fitzgerald, 39 William Street, Elmira, Ontario, N3B 1P3, or fax to (519) 669-3826, Email: susan.tfio@sympatico.ca

?2007 Canadian Certified Crop Advisor Association