Self Study NAC Workshop Form

Applicant Information
Sponsor of Workshop*
Name of Person Completing This Application*
First Last
Your Title*
Phone
Email*
Workshop Information
Date of Workshop*
MM slash DD slash YYYY
Title of Workshop*
Length of Workshop (Hours)*
Name of Instructor(s)
Educational Qualification of Instructor(s)*
Resume of Instructor (Optional)

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Experience Qualification of Instructor(s)*
Supporting Documents for Experience (Optional)

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Applicable NAC Core Competency/ Competencies*
Outline of Workshop*
Workshop Outline Upload (Optional)

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How is Your Organization Properly Scheduling Clients to Maximize Enrollment?*
Will there be any evaluation of the students?*
- Yes
- No
If You Answered 'Yes'; Please Describe the Evaluations*
What is the Value of the Workshop?*
If you answered 'Clock Hours' to the question above, how many?
Is the workshop approved for your state’s training requirements through your licensing agency?
- Yes
- No
Certification
By submitting this application, you certify that this information is accurate to the best of your knowledge.

Applicant Information