Continuing Education Annual Report
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Name of Provider
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Provider Number
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Provider Expiration Date (Renewal application is due 60 days before expiration date)
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Legal Body (if different from Provider)
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Street Address
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City
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State
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Zip Code
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Telephone #
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Email Address
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Program Coordinator
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Reporting Year
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Contact Information to be listed on KSBN Website
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Interactive Offerings
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Total Number of Offerings
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Total Number of LMHT Participants
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Offering Contact Hours taught: Sum of OH taught by each category total should be the same as Total Number of Offering Contact Hours”
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Nurses
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Independent Study Offerings
Complete only if you offer Independent Study
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Number of Independent Study topics offered:
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Attestation
I realize that this application is a legal document and by pressing the Submit button you are declaring under penalty of perjury under the laws of the State of Kansas that the information I have provided is true and correct to the best of my knowledge.
If all the above information is correct please press the Submit button .
Otherwise please go back and correct any information that is necessary.
SUBMIT WILL CONTINUE YOU ON TO THE FILE UPLOAD PAGE
