Application for CE Recognition
Date of Submission:
Organization Name:
Type of CE submission:
(If other, please describe):
Conference
Seminar
Webinar
Workshop Other
Meeting date(s):
Location (name of facility, city & state):
Please provide information below for the person responsible for or submitting this application:
Name:
Company/Affiliation:
Address:
City:
State:
Zip
Country:
Phone:
Fax:
Email:
The following items are attached (* signifies a required item):
 Program schedule with date(s) and
times for each CE presentation*
 Brief course descriptions for each CE
offering*
 The overall conference learning
objectives*
 Course learning objectives for each
CE offering*
 A list of at least five references
(research and/or theoretical)
supporting the content of your
presentation*
 A registration form
 The evaluation form(s) to be used for the
conference and each CE offering*
 Sample CE certificate showing CE credits to
be offered*
 Biographical sketches for each presenter*
 Conflict of Interest forms from each
presenter*
 CV’s for each presenter (NOTE: Do not
submitted CVs to AAPB. They must be
maintained in your records should your CE
offerings be audited by APA or should
AAPB require selected material for its
records).
1
Approved July 15, 2013
Fees:
Recognized AAPB Chapter or Section
FREE: _____
Organization with AAPB Liaison Relationship (attached liaison agreement)
Multi-session CE offering (conference or seminar)
$50:_____
Single session CE offering (i.e. workshop or webinar)
$25: _____
Distance learning (e-learning on demand, etc.):
$15: _____ x CE credit = $ _____
Non-AAPB-Chapter or organization with no standing liaison relationship
Multi-session CE offering (conference or seminar)
$120: _____
Single session CE offering (i.e. workshop or webinar)
$75: _____
Distance learning (e-learning on demand, etc.):
$30: _____ x CE credit = $ _____
Name
Title
Signature
Date
Submit this form and attachments to:
AAPB
info@aapb.org
or mail to:
10200 W. 44th Avenue, Suite 304
Wheat Ridge, CO 80033
303-422-8436
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Approved July 15, 2013