ATTENDANCE ROSTER

The program chairman who requested program approval is responsible for submitting attendance roster to  SNA-VA within (2) two weeks following activity.  Credit will be recorded for all certified participants.  The official roster will serve as verification of attendance; however, each individual should keep their own record of credits earned.

TITLE OF ACTIVITY:          ______________________________________________________________

DATE OF ACTIVITY:   _________________         SPONSOR:  _________________________________

ADDRESS: ____________________________________________________________________________

PRE-APPROVAL:________________________                 POST APPROVAL: _____________________

MAXIMUM CONTINUING EDUCATION CREDITS APPROVED:   _____________________________

NAME

SNA MEMBERSHIP NO.

NAME

SNA MEMBERSHIP NO.

                                                                        (Signature) _______________________________

                                                                                                  (Program Chairman)

Prepare in duplicate.  Send original to Elizabeth Wimmer, 5130 Hildebrand Road, Roanoke,VA 24012 and retain one copy for your file.            Incomplete forms will not be processed.