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PO Box 62495 – Harrisburg, PA 17106-2495 – (800) …

Pennsylvania Continuing Legal Education Board PO Box 62495 – Harrisburg, PA 17106-2495 – (800) 497-2253 Application for Approval of Continuing Legal Education

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Text of PO Box 62495 – Harrisburg, PA 17106-2495 – (800) …

Printable Form Instructions: Pennsylvania Continuing Legal Education BoardPO Box 62495 Harrisburg, PA 17106-2495 (800) 497-2253Application for Approval of Continuing Legal EducationThe application is available to complete andprint online. Click on the different sections of theform to begin typing. Use the tab key to advance to the next section. Print when the completed application to the PA CLE Board with: $25 application fee made payable to the PA CLE Board A program Agenda or Course BrochureUpon receipt and review, PA CLE will notify the applicant of the status of the course withinapproximately one week. Pennsylvania Continuing Legal Education Board PO Box 62495 Harrisburg, PA 17106-2495 (800) 497-2253 Application for Approval of Continuing Legal Education KH _______ APPLICATION TO THE STATE OF Please Check One: MCLE STATE NOTIFICATION OF ACCREDITATION To be completed by the PA Accreditation Department. Course Number: ________ Date: __________ The following action has been taken on this application: APPROVED for a total of __________ CLE credits Including __________ Ethics Credits NOT APPROVED (See comments below or additional information attached.) OTHER Regulator Comments: Is the Provider PROFIT NONPROFIT 1 SPONSORING ORGANIZATION INFORMATION NAME ADDRESS STREET CITY STATE ZIP TELEPHONE FAX EMAIL 2 TITLE OF EDUCATIONAL ACTIVITY 3 DATE(S) LOCATION(S) 4 REGISTRATION FEE: 5 WRITING SURFACE AVAILABLE: Yes No 6 METHODS OF PRESENTATION: Faculty in Room with Participants Telephone to Broadcast Site Live Web Cast Interactive Video Satellite Other: Audio Presentation Videotape Presentation Internet On-Demand (Interactive) Discussion Leader present 7 TYPE OF LAW CODE(S): (Available for review: ) 1. Additional Codes Optional: 2 3. 4. DEGREE OF DIFFICULTY: Beginner Intermediate Advanced All Levels 8 ADVERTISED TO: Lawyers Clients Others (Specify/Indicate %) 9 LIST ANY ADMISSION RESTRICTIONS: 10 IN-HOUSE ACTIVITY INFORMATION (See Local Rules for Applicability) Open/Publicized to Outside Lawyers Yes No Outsiders are _______ % of Faculty & Clients are ________ % of audience If not open, please specify reason: 11 METHOD OF EVALUATION: Participant Critique Independent Evaluator None Other: 12 MATERIALS DESCRIPTION Total Pages: ________ Loose leaf Bound No materials supplied Distributed: Before Program At Program Other: 13 REQUIRED ATTACHMENTS TO THIS APPLICATION APPLICANT IN FORMATION (please print) a. Time Schedule/Agenda (Brochure, Outline, Description) b. Table of Contents c. Faculty Description if not included in the brochure or description d. Application Fee - $25 payable to the PA CLE Board Sponsor Representative Name: Title: 14 CREDITS REQUESTED Complete the following if filed by individual attorney: Indicate minutes of instruction not including breaks, meals or introductions: (60 minute hour) Substantive: ______ Ethics: ______ Total: ______ Attorney Name & ID #: Address: City: State: Zip: Contact Number: Email: 15 ACCREDITATION BY OTHER STATES GRANTED: DENIED: 16 SUBMITTED BY Course Sponsor Individual Lawyer SIGN HERE Date: Please Complete and sign Applicant Information

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