This training documentation must be mailed to PCCG Continuing Education Report, PO Box – 1922, Lawrenceville, GA 30046. Attendance information is required for persons seeking credentialing or re-certification to receive appropriate credit. Failure to submit complete attendance information in a timely manner will result in the loss of PCCG credit for that training event. Repeated failures to submit complete attendance records as required may result in a loss of training provider privileges. Continuing Education Provider Application Organization Name: Contact Name: Address: City: State: Zip Code: Telephone: Email: Estimated number of times you will offer training this year: Would you like this conference listed on the PCCG Training calendar? ___Yes ___No Prevention Course(s) Details: Prevention Course Name Lead Trainer Hours Domain(s) Core Name/Credential Addressed Course? Ex: Fundamentals of Sue Sample/ICPS 12 I, III Yes Prevention Total Hours/Total Core Hours When submitting this application via email, please also attach training details including title, description, goals, objectives for each course applying for credit and promotional flyer (if applicable). Application will not be considered complete until this supplemental information is received.
This training documentation must be mailed to PCCG – Continuing Education Report, PO Box 1922, Lawrenceville, GA 30046. Attendance information is required for persons seeking credentialing or re-certification to receive appropriate credit. Failure to submit complete attendance information in a timely manner will result in the loss of PCCG credit for that training event. Repeated failures to submit complete attendance records as required may result in a loss of training provider privileges. Continuing Education Provider Application Organization Name: Contact Name: Address: City: State: Zip Code: Telephone: Email: Estimated number of times you will offer training this year: Would you like this conference listed on the PCCG Training calendar? ___Yes ___No Prevention Course(s) Details: Prevention Course Name Lead Trainer Name/Credential Hours Domain(s) Addressed Core Course? Ex: Fundamentals of Prevention Sue Sample/ICPS 12 I, III Yes Total Hours/Total Core Hours When submitting this application via email, please also attach training details including title, description, goals, objectives for each course applying for credit and promotional flyer (if applicable). Application will not be considered complete until this supplemental information is received.
PCCG-Continuing-Education-PROVIDER-App-1-17.docx