CLEreg 1 Uniform Application for Approval of Continuing Legal Education MCLE STATE NOTIFICATION OF ACCREDITATION To be completed by the MCLE State regulatory agency and returned to applicant. Course Number: ________ Date: __________ APPLICATION TO THE STATE OF: Mississippi Commission on CLE, P.O. Box 369, Jackson, MS 39205 SPONSORING ORGANIZATION INFORMATION NAME The following action has been taken on this application: ADDRESS APPROVED for a total of __________ CLE credits Including __________ Ethics Credits Other Credit Breakdown: ___________ CITY TELEPHONE FAX STATE EMAIL ZIP (if applicable) NOT APPROVED (See comments below or additional information attached.) 2 TITLE OF EDUCATIONAL ACTIVITY RETURNED for the request of additional information. Please complete each item on the form as indicated by the numbers circled below. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 3 DATE(S) LOCATION(S) OTHER Regulator Comments: 4 5 6 REGISTRATION FEE: WRITING SURFACE AVAILABLE: METHODS OF PRESENTATION: Yes No 7 8 9 10 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 TYPE OF LAW CODE(S): (Available for review: https://www.clereg.org/lawClassifications.asp) 1. Additional Codes Optional: 2 3. 4. DEGREE OF DIFFICULTY: Beginner Intermediate Advanced All Levels ADVERTISED TO: Lawyers Clients Others (Specify/Indicate %) LIST ANY ADMISSION RESTRICTIONS: 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: METHOD OF EVALUATION: Participant Critique Independent Evaluator None Other: MATERIALS DESCRIPTION Total Pages: ________ Loose leaf Bound No materials supplied Distributed: Before Program At Program Other: REQUIRED ATTACHEMENTS TO THIS APPLICATION: a. b. c. d. Time Schedule/Agenda (Brochure, Outline, Description) Table of Contents Faculty Description Complete Set of Materials and Fees (Only in states where required) Name: Title: Complete the following if filed by individual attorney: Attorney Name: Address: City: Contact Number: Email: State: Zip: 11 12 13 APPLICANT IN FORMATION Sponsor Representative (please print) 14 CREDITS REQUESTED: Indicate minutes of instruction not including breaks, meals or introductions: General/Substantive: Ethics: Substance Abuse: Other: Total: ______ ______ ______ ______ ______ 15 ACCREDITATION BY OTHER STATES: GRANTED: DENIED: 16 SUBMITTED BY: Course Sponsor Please Complete and sign Applicant Information Individual Lawyer SIGN HERE Date: American LegalNet, Inc. www.FormsWorkFlow.com