APPLICATION FOR CONTINUING
EDUCATION UNITS
Ohio University Community and
Professional Programs
Instructions:
Please print or type all information
and submit all required paperwork
• Certificate of Completion
for course or certificate program
• Complete a new CEU
Application Form for each course/certificate program
• A check made payable
to Ohio University in the
amount of $20.00/course or certificate program (plus an additional
$6 if applying from overseas).
Returned with all required forms
to: Community and Professional Programs,
Ohio University, 115 Haning
Hall, Athens, OH 45701
First Name: ____________________
Last Name:______________________
Address:
_____________________________________________________________
City: ________________________
State: _________ ZIP: ______________
Daytime Phone Number: (
) ________-__________
EMAIL Address: _________________________________________________
Name of Course/Certificate completed:
______________________________
Number of CEUs Requested: ________________
I certify that I completed the
above course/certificate program.
Signature: _______________________________________
Date: _________
Payment:
Check made payable to Ohio
University for $20.00
MasterCard Number: _______________________________
Exp. Date: ____
VISA Number: ____________________________________
Exp. Date: _____
Name on card: __________________________________________________
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