NAME:                                                                       STATE Cert. #       

COURSE TITLE:       

SPONSOR(S):        

DATE(S) ATTENDED:        

LOCATION:       

INSTRUCTOR(S):        

BRIEF DESCRIPTION OF COURSE: 

QUALIFICATIONS OF INSTRUCTOR(S): 

Please mark one item in each column below that applies to the course you attended.  This must be completed.

FIELD OF STUDY                      CATEGORY CLAIMED               SOURCE

  Accounting & Auditing             Seminar                                  Local Chapter

  Advisory Services                   College Credit Course            State Society

  Management                           Self Study                               Other State Society

  Personal Development           Video                                      Firm Associations

  Specialized Knowledge           Speaker/Disc Leader              Employer Provided in House

  Taxation                                  Published Articles/Books        College

                                                                                                        AICPA

                                                                                                        Other

Number of contact minutes you attended                                                                    

                                                                                                                                    ¸ 50  =

Number of CPE credit hours you are requesting                                                      

___________________________________     ________________________________

Signature                                                                   Date

PLEASE COMPLETE THIS REPORT IN FULL BY THE 1ST MONDAY FOLLOWING YOUR RETURN FROM THE COURSE.  YOUR CPE CREDITS ARE REPORTED TO THE STATE SOCIETY FROM THIS INFORMATION.