PDH Request Form

MM slash DD slash YYYY
Name of Organization or Company:
Name of Person Completing Application:
Representative Name and Title:
Representative Email and Phone:
Company Address:

MARKETING THE EVENT

Marketing brochure or online promotion of the course(s) must include: • Course description • Learning outcomes • Registration details • Speaker bio and credentials

Upload a copy of the marketing brochure, website, or marketing emails*

NOTE: We will not review and approve an application until we receive a copy of the marketing brochure or a link to a conference website. Marketing must include: Course description • Learning outcomes • Registration details • Speaker bio and credentials. EnviroCert International, Inc. (ECI) is certifying the educational contact hours of the program and by doing so is, in no way, endorsing any specific content, company, or product.
Type of Learning Event:

PRESENTER / TRAINER INFORMATION

Will more than one (1) presenter / trainer be approved to present this course?
* Please explain the credentials and experience of the presenter / trainer qualifies them to speak on this topic.

Presenter / Trainer Names and Credentials*

List the names and credentials of all presenters / trainers that will be approved to present this course.

Learning Design

Instructional Materials to be Used to Present Content
Method used to accommodate learning styles:

Learning Outcome

How is Learning Outcome determined ?

Fees

ECI OUTREACH

Does Group want ECI to send out PDH Announcement(s)?