Follow the steps to successfully complete the form.

1. Click the ‘Get Form’ button to access the form and open it in the editor.
2. Fill in the Requestor Information section by providing your identifying number, name, organization name, and mailing address.
3. Enter your contact information, ensuring you provide a reliable email and phone number for communication purposes.
4. If your mailing address differs from your physical business address, make sure to fill out the physical address section correctly.
5. In the Course Information section, select the type of education your course fulfills (Continuing Education or Qualifying Education).
6. Indicate the delivery mechanism for your course, specifying whether it will be presented in a classroom or through distance education.
7. Choose the appropriate application type: New, Renewal, or Update, depending on your circumstances.
8. Provide the course title and, if applicable, the course number that corresponds to the course you are submitting.
9. Specify the number of hours you wish your course to be evaluated for and identify the source of the course material.
10. Make sure to sign and date the form where indicated, confirming that the information provided is accurate.
11. Once you have completed all fields, you can save changes, download, print, or share the form as needed.

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