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*First Name

*Last Name

*Your Email

*Name of Course

*Date of Application

*Date of Course

*Name of Contact

*Address of Course

*Contact Phone Number

*Contact Email Address

*Purpose of Course

*Course learning objectives (must list at least 3)

*Name of credentials of all instructors

*Describe the experience the instructors have in teaching this course

*How many hours of continuing education are you applying for?

*Who is the target audience?

*Expected Enrollment

Course sponsor (if applicable)

Do you want to advertise this course through UOTA (if this is checked "Yes" a UOTA board member will contact you)
Yes