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