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Authorized Signature of RegionalEducation Committee Chairperson

Professional Opticians of FloridaApplication for Approval of Continuing Education

This form must be completed and submitted to POF headquarters no later than sixty (60) days prior to the dateof the program in order for approval to be made. This form must be completed in its entirety or your coursewill not be approved.

__________ __________________________________Today’s Date Chapter Name Contact Person (*Florida Licensed Opticians only)

____________________ ____________________ _______________________________________Contact Phone Contact Fax Contact E-mail

________________________________________ ____________________ _____ _________Contact Street Address City State Zip Code

__________ ______________ _______________________________________________________ProgramDate Total Program Hours Facility Name

________________________________________ ____________________ _____ _________Facility Street Address City State Zip Code

Course Information

________________________________________________________________________________________Course Title (*Product brand names cannot be included in course titles.)

_____________________________________ ___ Outline attachedCourse Instructor (*Required)

CE Slips by Mail ____ E-mail (*Enter recipient’s address below.)Course Category (*Choose only one.) Qty.

__________________________________________________ ____________Course Length Starting Time

Forward this form, alongwith a course outline and speaker resume, to yourRegional Education Committee Chairpersonw:

George Sweat Gloria Dodge3020 Hartley Road, Suite 190 1300 S Tropical TrailJacksonville, FL 32257 Merritt Island, FL 32952904-292-0004 Phone 321-986-8554 Phone904-292-0005 Fax Fax Same

They will in turn approve and sign the form and return it to POF headquarters at:

Provider # B00007

JJJohn Girdler8705 Minnow Creek DriveTallahassee, FL 32312850-264-6805johngirdler@h.com

50-1645

John Girdler8705 Minnow Creek DriveTallahassee, FL 32312850-264-6805 fax 850-201-2947johngirdler@hotmail.co

Submit 30 days in advance for approved speakers & courses

Submit 60 days in advance if a new speaker or new course topic

This form must be completed in its entirety for your course to be approved.

MM/DD/YYYY

(###) ###-#### (###) ###-#####

FL

MM/DD/YYYY

FL

POF • P.O. Box 1296 • Crawfordville, FL 32326 • Fax (850) 201-2947

Please fill out one form per course