Applicant's Name

Applicant's Email

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Program's Title

Program's Start Date

Program's End Date

Teacher's Name

Teacher's Email

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Co-Teacher's First Name

Middle

Last Name

Co-Teacher's Email Address

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Venue Name

Address

City/Town

State/Province

ZIP/Postal Code

Country

Total number of participants (including non-psychologists):

Total number of Psychologists:

Total number of Participants who obtained APA CE credit:

Price: $30.00 Quantity:

Total number of Participants who obtained BRN CE credit:

Price: $30.00 Quantity:

Total number of Participants who obtained APA CE credit for courses 6-hours or less

Price: $15.00 Quantity:

Total number of Participants who obtained BRN CE credit for courses 6-hours or less

Price: $15.00 Quantity:

Upon submission of the CE Co-Sponsorship Application form, you must email the Center for Mindfulness at mindfulness@health.ucsd.edu to complete the payment for the total CE fees collected.

Total $0.00

Scanned Sign-in Sheet (signed by all participants) is required with license information of participants who are obtaining CE credit.

Please upload scanned Sign-in Sheet for the course described above.*

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Copies of course evaluation forms

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CE Credit Co-Sponsorship Post-Course Application

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