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Program Sponsor Application

Cover Page

Licensed Marriage & Family Therapists

Continuing Education Certification Program

Massachusetts & Rhode Island

 

List each enclosed application by start date and proposed number of contach hours. Circle the state(s) you want certification for. Enter the application fees and total due. Please submit your application package and fees with this as the first page. Use additional copies of this cover page as needed. See also: "Information for Sponsors" and "Application by Program Sponsor".

Sponsoring Organization: _____________________________________ Today’s Date: _________________

Start Date

State(s)

Contact Hours

Massachusetts

Rhode Island

1. _____________

MA / RI

__________

____ ($15/$25/$35)

____ ($15/$25/$35)

2. _____________

MA / RI

__________

_______ ($15)

_______ ($15)

3. _____________

MA / RI

__________

_______ ($15)

_______ ($15)

4. _____________

MA / RI

__________

_______ ($15)

_______ ($15)

5. _____________

MA / RI

__________

_______ ($15)

_______ ($15)

6. _____________

MA / RI

__________

_______ ($15)

_______ ($15)

7. _____________

MA / RI

__________

_______ ($15)

_______ ($15)

8. _____________

MA / RI

__________

_______ ($15)

_______ ($15)

9. _____________

MA / RI

__________

_______ ($15)

_______ ($15)

10._____________

MA / RI

__________

_______ ($15)

_______ ($15)

Cover Page # _____ of _____

Column Total

$_________

$________

Total fees for this page:

$________

Total fee enclosed (for all Cover Pages):

$________

 

Fees:

 

1. For the activity listed that offers the highest number

of contact hours (for each state):

2. All subsequent activities submitted in the same package: Any number of hours: $15.00 each

1.0 up to 4.0 hours:

4.5 up to 14.0 hours:

14.5 or more hours:

$15.00

$ 25.00

$ 35.00

3. Add second state: 1st activity is $15/$25/$35. Additional activities, any number of hours: $15.00 each.

 

Please make checks out to: "FDA/CE Certifications" (Institutional order forms accepted with 30 days net.)

Submit all materials to:

Michael I. Vickers, PhD

voice 508.877.3660 extension 6

Continuing Education Administrator

fax 508.872.6330

Family Development Associates

email: m-vickers@comcast.net

40 Speen St., #106
Framingham, MA 01701

web page: www.mftce.com

Note: Lists of certified activities, application forms, CE regulations and

LMFT license regulations can be found on our web site.

www.mftce.com