Kansas Mechanical Trades Review
Board
Request for Continuing Education Approval
Please attach a copy of:
· Class Agenda or Course Outline
· & Instructor Biography or Resume
NOTE: IF THE APPLICATION IS INCOMPLETE OR THE COURSE OUTLINE & INSTRUCTOR
BIOGRAPHY ARE NOT INCLUDED, THE REQUEST WILL BE RETURNED.
Title of
Program:____________________________________________________________________
Sponsoring Group:__________________________________________________________________
Contact Person:____________________________________________________________________
Telephone:__________________ FAX:
_________________ E-Mail: __________________________
Mailing Address:____________________________________________________________________
City: __________________________________________ State: ___________Zip:______________
Date of Seminar: __________________ Time (Start / Finish) of Seminar:________________________
Total Hours of Instruction: _____ Course Cost:___________ Course Capacity:____________________
(IF SAME COURSE WILL BE HELD ON
MULTIPLE DATES AND/OR LOCATIONS,
PLEASE ATTACH A SEPARATE SHEET
INDICATING THE ADDITIONAL INFORMATION)
Location:___________________________________________________________________________
Address:____________________________________________________________________
City:__________________________________________ State:
___________Zip:_______________
Instructor's Name:___________________________________________________________________
A $35.00 Processing Fee is Required for Each Application. Contact the
Kansas Building Trades Review Board at the Address Listed Below to
ArrangePayment.
Submit to: Kansas Building Trades Review Board
C/O
Kansas PHCC Association
1632 S. West Street, Suite 3
Wichita,
KS 67213
Phone:
(316) 943-7100 Fax: (316) 943-7108 WEBSITE: kphcc.org
TO BE COMPLETED BY THE KANSAS MECHANICAL TRADES REVIEW BOARD
Board Group Name:_____________________________________________________________
Approved____ Signature: ________________________________________Date: ________
Not Approved ____ Signature:
________________________________________Date:________
COURSE IDENTIFICATION NUMBER:______________________________________________