ACTIVITIES AND CREDITS FORM FOR CEUs TO MAINTAIN CPCC, CPCC-I and CPCC-R CERTIFICATION

Instructions: Fill in the blanks according to the column heading. CLICK HERE for an approved list of activities and assigned Continuing Education Units (CEUs). If you believe you should receive credit for an item not on the approved list, add it and the Certification Board will consider its approval. Also, forms from other certification programs will be accepted and assigned the correct CEU credits for the CPCC and CPCC-I programs. *Keep supporting CEU documentation for at least 2 years. You may copy this form and submit items throughout the year as you participate in them. You will receive email copy after you submit this form. Fees is $40 for members, $90 for non-members and $65 for dual certification. Payment can be made using secure server after submission of this form.
	Name		State
	Company		Zip
	Address		Email
	City		Phone
CPCC-I CPCC-R CPCC	Check all that apply		Fax
			Certificate #

Date	Code #	Activity Description	Sponsor & Location	CEU	Contact hours

Please copy the image below: