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OPA-MCE Distance Learning Notification Form
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OPA-MCE Distance Learning Notification Form 2016-2018 Ohio Psychological Association Mandatory Continuing Education Office 395 East Broad Street #310 Columbus, Ohio 43215 Phone 888-672-6231 or 614-224-9620 Fax 614-224-6702 mce@ohpsych.org


Photocopy this form as necessary.

PROVIDER ORGANIZATION


COURSE INFORMATION




PRIMARY INSTRUCTOR INFORMATION


CO-SPONSORSHIP INFORMATION
(Complete the following information only if course is co-sponsored with another organization.)


Attach a list of psychologists (including their license number) who have taken this course. Repeat this process each quarter. Lists should be emailed to mce@ohpsych.org or faxed to 614.224.2059.

AUTHORIZATION


 I certify, on behalf of the CE Provider Organization that completed this application that the preceding statements are true. I understand that any false statements may result in the revocation of the provider approval. I understand that I am responsible for maintaining all standards outlined in the Provider’s Agreement and the Polices and Procedures Manual. I also understand that this course may be subject to an announced, random administrative audit.