CEU Program Packet - Northeast Mississippi Community College

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NEMCC ~ CONTINUING EDUCATION
PROGRAM FORM
NOTE: Program Form must be completed by the coordinator or instructor of the workshop. Program
Form must also be turned in to the office of the Continuing Education prior to the starting date of
the workshop.
Date: __________________
Title of Class: _________________________________________________
Educational Objective: ____________________________________ _____
____________________________________________________________
Target Audience:
________________________
Anticipated Attendance: ___________________________
Contact Person: ________________________________
Address:
_____________________________
Telephone Number (Day): _____________FAX Number: _________
E-Mail: ________________________________________
Name of Instructor:
_____________________
Address:
Telephone #:
Day
Evening
E-Mail: ________________________________________
Date for Class:
Time for Class:
_______________
__________________________________
Location of Class:
________________________________________
*Total Contact Hours (omitting breaks and lunches):
CEU’s Available (NEMCC CE Office Use Only):
* Timed Agenda
Must Be Attached
TRAINEE EVALUATION OF
CLASS & INSTRUCTOR
Industry or Business Name: ____________________________
Class or Course Name:
____________________________
Instructor(s) Name(s):
____________________________
Class or Course Date(s):
____________________________
Please complete the evaluation questions below by checking the block below one of the five responses.
Excellent Good Satisfactory
Needs Improvement
How were the classroom/facilities?
How were the materials, books, audio-visuals, etc. (if used)?
How was the instructor’s knowledge of the course content?
Rate the instructor’s presentation (speaking ability, organization,
punctuality, response to questions).
As to meeting your needs, rate the class time (day of week, time of day).
How useful was this training in the completion of your job responsibilities?
The length of the class was appropriate.
You were given ample opportunity to participate in the class.
After this class, you feel prepared to start or continue working on this topic
on your own.
What newspaper or online publication do you read on a regular basis? ___________________________________________
Problem Area
Name of Training:
Date:
Time:
Location:
Purpose:
ROSTER FOR ATTENDEES
* At the conclusion of each workshop, please mark (C) complete or (I) incomplete for each participant.
Name (Print)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Name (Signature)
*C / I
Northeast Mississippi Community College
Continuing Education Unit Program
“PARTICIPANT CEU REQUEST”
Payment must be received with request. Please indicate payment method below.
Please Print
Name of Training___________________________________________________
_______________________________________________________________________________
Name
Last
First
Middle Initial
_______________________________________________________________________________
Permanent Home Address (P.O. Box or Street)
_______________________________________________________________________________
City
State
Zip Code
County
E-mail
_______________________________________________________________________________
Social Security Number
Date of Birth
Telephone
Payment: $10.00 per request
Date of Training________________________
CASH ( ) _____________ CHECK ( ) #_______________
DEBIT/CREDIT CARD
Name on Card: ______________________________ Card Number:
________________________
Expiration Date: ________________________
Type of Card: Credit ( ) Debit ( )
Amount: _______________________
Name of Card: MasterCard ( ) VISA ( ) Discover ( )
___ ___ ___
Office Use Only:
Processed By______________________
Date___________________
AR__________
BO___________
Spaiden _________  Yes  No
3 Digit Security Code:
Fax or Mail Request to:
662-720-7896
Continuing Education
NEMCC
101 Cunningham Blvd.
Booneville, MS 38829
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