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FORM FOR REPORTING SOCIAL WORK …

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January 15, 2015 This form is only for use when a continuing education provider does not provide a certificate of attendance. FORM FOR REPORTING SOCIAL work continuing education Name of Licensee ______________________________________Li cense Licensee's Address ________________________________________ __________________________ Title of Session_________________________________ ____________________________________ Sponsor ________________________________________ __________________________________ Date(s) & Time of Attendance ________________________________________ ________________ Amount of Credit Received ________________________________________ __________________ Actual time spent in session The instructor, sponsor, leader, training coordinator, or agency director must sign below attesting to attendance.

January 15, 2015 This form is only for use when a continuing education provider does not provide a certificate of attendance. FORM FOR REPORTING SOCIAL WORK CONTINUING EDUCATION

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