Application

Certificate of Continued Studies Program

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Application

Please print and complete this application.

Then either e-mail it to the CIEA

or send it via the US Postal Service

at the address given below.

APPLICATION FOR ACCEPTANCE INTO THE

Certificate of Continued Studies

PROGRAM

Date ____________

NAME ____________________________

ADDRESS _________________________

CITY ___________ STATE __________

ZIP ________ PHONE( )__________

Professional License # __________

Type of License__________________

Soc. Sec. # _____________________

List the CIEA self study courses

you have completed

_________________________________

NOTE : If you are an unlicensed professional please include a letter of reference from your current employer

COST : Application fee and postage and handling for your certificate is $15.oo. Please enclose this amount with your order.

Central Institute for Educational Advancment

P.O. Box 750491

Dayton, Ohio 45475-0491