Application for Approval of Continuing Education Activities

Contact Information:

First Name:
Last Name:
Email:
Program date:

Contact hours are requested for (choose one):

General Information

Sponsoring Group:
Program Coordinator:
Address:
City:
State:
Zip:

Title of Presentation:
Location of Presentation:
Estimated Attendance:

Program Coordinator Information

First Name:
Last Name:
Email:
Highest level of education completed:
Professional Certificates:
Nephrology related experience:
Experience in planning renal technology education programs:
List all members of the planning committee for this educational activity:

Speaker Information

First Name:
Last Name:
Email:
Position:
Relevant Past Experiences:
How was the speaker involved in planning this program/offering?:

Contact Hours Requested

Total number of minutes of presentation:
Total Contact Hours Requested:
Check this box to confirm you will send in an attachment of the program for review once this application is submitted to nant@meinet.com
   - denotes required fields