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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the Course Application Fees. Input the base fee of $50.00 and calculate additional fees based on content review, classroom delivery, or distance education as applicable.
- Fill in your Provider License Number and Provider Name along with your contact information including phone number and email address.
- Select the Course Title from the provided options, ensuring you choose only one per application. Indicate the Delivery Method that applies to your course.
- For Distance Education courses, provide detailed explanations for student identification verification, required hours completion, interaction methods with instructors, and final exam administration processes.
- Finally, ensure all fields are completed accurately. Print your name, title, sign the document, and date it before submission.
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