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Application For Accredited Provider Status - New York
| Application For Accredited Provider Status Form. This is a New York form and can be used in Attorney Admission And Continuing Legal Education Attorneys Statewide . |
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New York State Continuing Legal Education Board 25 Beaver Str eet, Room 888, New York, NY 10004 Phone: (212) 428- 2105 Fa x: (212) 42 8-29 74 Webs ite: www.nycourts. gov/attorne ys/cle E-mail: cle@court s.st ate. ny.usAPPLICATION FOR ACCREDITED PROVIDER STATUS SPONSORING ORGANIZATION:______________________________________________ REQUIRED ATTACHMENTS: (Please submit an original and one copy of the completed__________________________________________________________________________ application and supporting materials.) For THREE COURSES, one from each of theADDRESS:________________________________________________________________ preceding three years, please submit the__________________________________________________________________________ following information: PHONE:_____________________________ FAX:_________________________________ 9 title of each course E-MAIL:___________________________________________________________________ 9 date(s) and location(s) of course 9 registration fee NAME AND TITLE OF CONTACT PERSON:____________________________________ 9 timed agenda or timed outline of course__________________________________________________________________________ 9 brochure or advertisement (if not NUMBER OF CLE COURSES SPONSORED, ORGANIZED AND ADMINISTERED BY available, provide course description) 9 faculty name(s) and credentialsYOUR ORGANIZATION DURING THE PAST THREE YEARS:_____________________ 9 detailed description of written materialsPLEASE DESCRIBE THE CONTINUING LEGAL EDUCATION ACTIVITIES OF YOUR distributed for the course ORGANIZATION OVER THE PAST THREE YEAR S, AND ATTACH A LIST OF CLE COURSES PRESENTED BY YOUR ORGANIZATION DURING THAT TIME, 9 total hours of CLE instruction (based onINCLUDING THE TITLE, DATE AND LOCATION OF EACH COURSE: a 50-minute hour, not including breaks, meals or introductions) __________________________________________________________________________ 9 breakdown of CLE credit hours into the__________________________________________________________________________ applicable categories: Ethics and Professionalism, Skills, Law Practice__________________________________________________________________________ Management, Areas of Professional Practice DOES YOUR ORGANIZATION PLAN TO OFFER COURSES IN NEW YORK DURING THE NEXT YEAR? 9 audience to which the course is directed and advertised 9 YES 9 NO _PLEASE DESCRIBE YOUR ORGANIZATIONS FINANCIAL AID POLICY AND 9 admission restrictions, if any PROCEDURES. INCLUDE THE SPECIFIC APPLICATION PROCEDURES AND THE 9 description of method of evaluating theELIGIBILITY REQUIREMENTS FOR SUCH AID. PROVIDER APPLICATIONS THAT course, e.g., participant critique,DO NOT INCLUDE A FINANCIAL AID POLICY FOR COURSES OFFERED TO NEW independent evaluation, otherYORK ATTORNEYS FOR A FEE ARE INELIGIBLE FOR CLE BOARD REVIEW. (ATTACH ADDITIONAL SHEETS IF NECESSARY): 9 method of presentation, e.g., faculty in room with participants, audiotape,__________________________________________________________________________ videotape, CD-Rom, video replay, teleconference, online, etc.__________________________________________________________________________ 9 verification procedures for __________________________________________________________________________ nontraditional formats and a sample of each format, where applicable__________________________________________________________________________ LIST OTHER STATES GRANTING OR DENYING ACCREDITED PROVIDER STATUS AND INCLUDE SUPPORTING DOCUMENTATION WHERE APPLICABLE: __________________________________________________________________________ Provider acknowledges and agrees to comply with all Program Rules and CLE Board Regulations and Guidelines, and cert ifies thatthe above information (including all attachments) is true. __________________________________________________________________ PROVIDER REPRESENTATIVE AND TITLE __________________________________________________________________ SIGNATURE DATE09/04 American LegalNet, Inc. www.USCourtForms.com
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