ApplicationForCourseApproval

Beforecompletingthisapplication,theapplicantshouldreadtheContinuingEducation

Rulesfoundin21NCAC12,aswellastheCourseDevelopmentGuidelinesdocument.

x Eachcourseapprovalrequestmustbesubmittedonaseparateapplication.

x TheApplicationForCourseReviewmustbesubmittedwithpaymentofrequiredfeesͲcoursereviewwillnotbegin

untilthereviewfeehasbeensubmitted.

x FeesarenonͲrefundable.

x Informationonthisapplicationmustbetypewritten.

x WůĞĂƐĞƐĞŶĚŽŶůLJƚŚĞĂƉƉůŝĐĂƚŝŽŶ͕ŶŽƚƚŚĞĞŶƚŝƌĞŽƵƌƐĞƉƉƌŽǀĂůƉƉůŝĐĂƚŝŽŶWĂĐŬĞƚ͘

Legal Name

of Applicant ___________________________________________________________

The applicant is the entity or person applying as provider of continuing education courses. If applicant is a corporation, partnership, or LLC, list the company as the applicant.

Applicant’s Mailing Address: ____________________________________________

______________________________________________________________________

City State Zip

County____________________ Telephone Number ___BB___________________

Provider Number (if known): ___________________

CE Coordinator Name __________________________________________________

CE Coordinator Email _____________________________________________

CE Coordinator Phone (Office)______________ (Cell)_________________

______________________________________________________________________

______________________________________________________________________

Number of CE Credit Hours Requested_________________

+RZZLOOWKHFRXUVHEHGHOLYHUHG"<RXPD\VHOHFWERWKLQSHUVRQDQGYLUWXDO6'/GHOLYHU\RSWLRQVRQWKLVVDPH

DSSOLFDWLRQH/HDUQLQJDV\QFKURQRXVFRXUVHVUHTXLUHVHSDUDWHDSSOLFDWLRQ

LQSHUVRQWUDGLWLRQDOFODVVURRPVHWWLQJ

YLUWXDOV\QFKURQRXVGLVWDQFHOHDUQLQJSODWIRUPDXWKRUL]HGWKURXJK11

eLearning (asynchronous) VHH&RXUVH'HYHORSPHQW*XLGHOLQHVLQWKLVSDFNHWIRUVSHFLILFVUHODWHGWRH/HDUQLQJ

You must include a separate document with H/HDUQLQJcourse materials that includes:

••

+RZZLOOWKHFRXUVHEHGHOLYHUHG"<RXPD\VHOHFWERWKLQSHUVRQDQGYLUWXDO6'/GHOLYHU\RSWLRQVR<< QWKLVVDPH DSSOLFDWLRQH/HDUQLQJDV\QFKURQRXVJJ FRXUVHVUHTXLUHVHSDUDWHDSSOLFDWLRQ

You must include a separate document with H/HDUQLQJ course materials that includes:

• &RPSOHWH LQstructions for accessing the course.

• The link for accessing the course.g

• 5 unique log-in credentials (see JXLGHOLQHVIRUVSHFLILFV

LQSHUVRQWUDGLWLRQDOFODVVURRPVHWWLQJ

YLUWXDOV\QFKURQRXVGLVWDQFHOHDUQLQJSODWIRUPDXWKRUL]HG WKURXJK 11

eLearning (asynchronous) VHH &RXUVH'HYHORSPHQW*XLGHOLQHV LQWKLVV SDFNHWIRUVSHFLILFVUHODWHGWRH/HDUQLQJW 

6WXGHQWKDVGD\VWRFRPSOHWHWKHFRXUVH\

&RXUVHVFDQQRWEHSXUFKDVHGVWDUWHGRUFRPSOHWHGDIWHU1RYHPEHUWKDQGGXULQJ'HFHPEHUJ ,QVWUXFWLRQVRQKRZWRVHDUFKDQGFRQILUPWKHLU4XDOLILHU,'DQG4XDOLILHUQDPHRQILOHZLWK1&/%*&

6XSSRUWHPDLODQGSKRQHQXPEHU

7HFKQLFDOV\VWHPUHTXLUHPHQWVLQFOXGLQJFRQQHFWLYLW\UHTXLUHPHQWVRSHUDWLQJV\VWHPYHUVLRQ LPSDFW\  J \ J RIDGEORFNHUVZKHWKHUDFFHVVWRVSHDNHUVRUDSULQWHULVUHTXLUHGDQGVRRQ

&HUWLILFDWHRIFRPSOHWLRQDFFHVV LIWKHVWXGHQWUHFHLYHVWKLVLQIRUPDWLRQLQDQHPDLOSOHDVHLQFOXGHD VDPSOHRIWKHHPDLOODQJXDJHWKHVWXGHQWUHFHLYHV

,IDQ\RIWKHIROORZLQJLQIRUPDWLRQDSSHDUVRXWVLGHWKHFRXUVHOLQNLHRQ\RXUZHEVLWHRULQWKH\ J  \ PDUNHWSODFHWKHQ\RXPXVWVXEPLW DVHSDUDWHGRFXPHQWWKDWLQFOXGHVWKH85/V

Yes (if yes, answer the following)

Content Owner’s Provider Name____________________________________

Content Owner’s Board-approved Provider # (if known) ________________

Board-approved Course ID#_____________________

No (if no, continue to the next question)

<HVLI\HVSURFHHGWRWKHTXHVWLRQLQWKHDSSOLFDWLRQWLWOHG%ULHI%DFNJURXQG2YHUDOO3XUSRVHRIWKH&RXUVH

No (if no, the Content Use Authorization Form must be submitted with this applicationLIWKHHQWLUHFRXUVHLV

RZQHGE\VRPHRQHHOVH7KH8VHRI,QWHOOHFWXDO3URSHUW\,PDJH'LDJUDP,OOXVWUDWLRQRU9LGHR

$XWKRUL]DWLRQ)RUPPXVWEHVXEPLWWHGZLWKWKLVDSSOLFDWLRQLIVRPHRQHHOVHRZQVLQWHOOHFWXDOSURSHUW\

FRS\ULJKWHGWUDGHPDUNHGRUSDWHQWHGLWHPVLPDJHVGLDJUDPVLOOXVWUDWLRQVRUYLGHRV DSSHDULQJLQWKH

FRXUVH7KHVH formV, found on the Board’s website, acknowledgethe content owner gives you permission to use the FRXUVHcontent RUDVVHWVfor the purpose of offering as a course for continuing education credits through the North Carolina Licensing Board for General Contractors. Failure to include WKHDSSURSULDWH properly completed and signed form will result in a denial of this application))

,VWKHFRQWHQWRZQHUD%RDUGDSSURYHGSURYLGHUIRUWKLVFRXUVH"

Course Objectives/Learning Outcomes (What will the student be able to do after completion of the course?)

Teaching Techniques Planned for the Course (lecture; question & answer; case studies;

demonstrations; group discussions; role plays; games; etc)

Equipment; Videos; flipcharts; computers; etc)

List of Instructor(s) to Teach the Course (if currently known) *Please note - Provider must submit an “Application For Instructor of Continuing Education” LIQRWDOUHDG\DSSURYHGDVDQ

LQVWUXFWRUZLWKWKH%RDUGas well as a “Provider Acknowledgement of Instructor Approval Form” for each instructor.

___________________________________________________

___________________________________________________

___________________________________________________

___________________________________________________

Checklist of additional items that must be included with this application:

(OHFWURQLFFRS\SGIIRUPDWHWF of powerpoint slides,course manuals, LQVWUXFWRUQRWHV etc

that clearly demonstrates the entirety of course content,IWKLVLVDQDV\QFKURQRXVFRXUVHD

GRFXPHQWRILQVWUXFWLRQVIRUDFFHVVLQJJDWHGDQGXQJDWHGYHUVLRQVRIFRXUVHDQGRUDQ\

DGGLWLRQDO85/VSOXVDGRFXPHQWRIDOONQRZOHGJHFKHFNDQGTXL]TXHVWLRQVDQGDQVZHUV

A timed course outline or syllabus, including breaks and mealtimes6KRXOGUHIOHFWH[DFWO\

PLQXWHVRILQVWUXFWLRQDOWLPHIRUDKRXUFRXUVHRUH[DFWO\PLQXWHVIRUDKRXUFRXUVH

6HHH[SODQDWLRQRIUHTXLUHGGHWDLOVDQGVDPSOHLQ&RXUVH3DFNHW

(OHFWURQLFFopies of any student materials (optional as inclusion to this application; however, all students must receive either a hardcopy or electronic copy of the material presented and must be available upon request to the Board)

A fully completed and properly signed Content Use Authorization Form, if current applicant is not the course content owner.

,I WKLV LVDQ DV\QFKURQRXVFRXUVH

y y \

GRFXPHQWRILQVWUXFWLRQV IRUDFFHVVLQJJDWHGDQGXQJDWHGYHUVLRQV RI FRXUVH DQGRU DQ\J J J \ DGGLWLRQDO85/VSOXVD GRFXPHQWRIDOONQRZOHGJHFKHFNDQGTXL]TXHVWLRQVDQGDQVZHUV

6HHH[SODQDWLRQRIUHTXLUHGGHWDLOV DQGVDPSOHLQ&RXUVH 3DFNHW\ A timed course outline or syllabus,

Thisapplicationmustbesignedbytheowner(ifsoleproprietorship),amanagingpartner(ifa

partnership),oramajorofficerauthorizedtosubmitsuchapplication(forothertypesofbusiness

entities).Ifapplicantisacommunitycollegeorcollege/university,theapplicationmustbesignedbythe

viceͲpresidentordeanresponsiblefortheinstitution’scontinuingeducationprogram(orbythe

institution’spresident).

Iherebycertifythatallinformationsubmittedinconnectionwiththisapplicationistrueandaccuratetothe

bestofmyknowledgeandbelief.Iunderstandthatomissionorinaccuracymaybegroundsfordenialof

approval,andthattheapplicantandallpersonsinitsemploywillcomplywiththetherequirementsofthe

NorthCarolinaLicensingBoardforGeneralContractorsregardingtheconductofcontinuingeducationcourses.

Printed Name and Title of Applicant or Legal Designee: ________________________________

Signature of the Applicant or Legal Designee: _______________________________________

___________________

Date