Professional Acknowledgment for Continuing Education 6701 Democracy Blvd., Suite 300 Bethesda, MD 20817 Phone: 301-657-2768 FAX: 301-657-2909 This form designates the organization's Program Administrator and is required to be completed when applying for the Annual Providership. Information should be condensed to fit this page only. DO NOT add additional pages. Name:______________________________________________________________________ Present Position: ____________________________________________________________________ Office Address:______________________________________________________________________ Phone: ______________________ Fax: _____________________ email: _________________ Degrees:_____________________________________________________________________ ____________________________________________________________________________ Specialized Training (include dates of internships, residencies, fellowships, etc.): ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Professional appointments: _____________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Certification/Licensure: ______________________________________________________________ ____________________________________________________________________________ Professional activities: ______________________________________________________________ ____________________________________________________________________________ Selected bibliography (list recent representative publications): ____________________________________________________________________________
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