CIM Continuing Education Credit Form

CIM's Information

Name

First Name *

Last Name *

Email address *

Phone number *

Course Information *

Course Title *

Location of course *

If online, please specify the organization and website URL

Instructor's contact information *

Please provide the name and an email or phone number of the person leading the course.

Brief description *

Please identify at least 3 lessons you learned through this course *

Start date *

If viewing an online/on-demand course, please provide the date(s) you viewed the material.

End date *

Length of course in hours *

Identify Course Category *

Select the course category (one only):  Business / Leadership / Maintenance / Moisture Mitigation / Product Training / Product Management / Standards / Subfloor Preparation 

If this course was NOT provided by FCICA at least one document proving course completion is REQUIRED *

Proof of successful course completion

i.e. grade report, completion certificate, letter from instructor, etc. You may also want to retain any additional handouts, timelines, brochures, etc. which may aid in evaluation of this course.

20MB max

Additional proof of successful course completion (optional)

I affirm the above information is complete and accurate and I successfully completed this course.

I agree