CERTIFICATION ACTIVITY APPROVAL FORM

Rev. 12/06                                                                                                                   Chapter # _____

Check One:     _____ Pre-Program Approval (for group and chapter activities).  Allow a minimum of

                                    three (3) weeks for processing.

                        _____ Post-Program Approval (for individuals, group, and chapter activities).

                                    Submit within thirty (30) days of completion of activity.

                        _____ Course Work Approval (for completion of academic course work).  Include

                                    official grade report or transcript.  Submit within six (6) months of completion

                                    of academic course work.

Type of Activity ___________________________________________________________________

Location of Activity ________________________________________________________________

Date of Meeting ___________________________________________________________________

Number Clock Hours Requested ______________    Date Submitted __________________________

Submitted by:  _____________________________________________________________________

         Address:  ____________________________________________________________________

         Phone # : ___________________________________ E-mail : __________________________

Enclose or e-mail a  copy of the program including the following information:

· Name of speaker

· Speaker's qualifications

· Title and Length of Program

· List knowledge or skills to be gained by participants

· For course work, attach catalog or course outline

_________________________________________________________________________________

_________________________________________________________________________________

Prepare in duplicate.  Send two copies to Elizabeth Wimmer 5130 Hildebrand Road,  Roanoke  VA 24012.  One copy will be returned for your records. INCOMPLETE FORMS WILL NOT BE PROCESSED. If e-mailing send completed forms and attach supporting documentation to elwimmer@aol.com

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(OFFICIAL USE ONLY)

______________________________                                    ______________________________

            (Approved)                                                                               (Credit Hours)

______________________________                                    ______________________________

          (Not Approved)                                                                                        (Date)