INSTRUCTIONS: Complete all items required below.  Please mail two copies of course material, completed NRSB Course Approval form, and application fee to: The NRSB, 14 Hayes Street, Elmsford, NY 10523.  To calculate Fee:  Number of credits _____ x $25= ______Total Fee   For Example: 8 credits x $25.00=$200.00 (Total Fee)

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Address_______________________________________________________________________

______________________________________________________________________

Phone #____________________________________Fax # _____________________________

E-mail ______________________________________________________________________

2. Have you ever had a course previously approved by the NRSB?__________________________

If so list one course by title_______________________________________________________

3. Type of Activity (short course, publication, attendance at meeting)

4. Presentation method: (e.g. Lecture, Video, Distance Learning, etc.)

5. Attach Outline or Syllabus of Course

6. Attach copy of certificate of course completion

7. Activity Duration (if applicable)

Contact Hours______ Days_______ Semester Hours______ Other _____

8. Course Title:___________________________________________________________________

9. Course Dates:___________________________# of Hours_______________________________

10. Course Instructors:______________________________________________________________

11. Location of Activity: ________________________________________________________

12. Other Relevant Information (include measurement tool):

______________________________________________________________________________

______________________________________________________________________________

13. Attach appropriate Resume and/or credentials supporting this request.

14. Requestor’s Signature________________________________________________Date_________

Application No.:__________________________________ Date Rec’d_____________________________

Instructor Approval:______________________________________________________________________

Name of Reviewer (Print)_________________________________________________________________

Education Committee Member:__________________________________________Date_______________

Signature

Date Course Provider Notified_____________________________________________Expiration________