New York State Continuing Legal Education Board 25 Beaver Street, Room 888, New York, NY 10004 • Phone: (212) 428-2105 Fax: (212) 428-2974 • Web site: www.nycourts.gov/attorneys/cle • E-mail: cle@courts.state.ny.us APPLICATION FOR ACCREDITATION OF AN INDIVIDUAL COURSE ACTIVITY (FOR USE BY AN INDIVIDUAL ATTORNEY SEEKING CREDIT FOR PARTICIPATION IN A PROGRAM) Each attorney requesting CLE credit must complete and submit an application form and include all required attachments (items 1 - 11). If you are seeking credit as a presenter, you must also describe your participation in the course, as requested in item 12. Please note that, generally, CLE credit is awarded only for courses/sessions that are specifically tailored to attorneys and that have significant legal content. Applications must be postmarked within 30 days of the completion of the course or program. See New York State CLE Board Regulations and Guidelines § 8(A)(3)(b). ____________________________________________________________ NAME OF ATTORNEY REQUESTING CREDIT: REQUIRED ATTACHMENTS in support of your application: 1. Attach a brochure, advertisement or announcement for the course (if not available, provide a course description). 2. Attach final version of the timed agenda or timed outline of course (if multiple sessions, indicate sessions attended). 3. Clearly indicate on the timed agenda/outline all session(s) for which you seek CLE credit in Ethics and Professionalism. 4. Attach proof of your attendance, such as a certificate of attendance signed by the sponsor. (Please note that confirmation of payment for a conference does not constitute proof of attendance.) __________________________________________________________________________ YEAR ADMITTED IN NEW YORK: ___________________________________________ MAILING ADDRESS: _______________________________________________________ 5. Attach a printed copy of the complete set of written materials distributed for the course. You must organize the materials so that they correspond to each session listed on the agenda. __________________________________________________________________________ PHONE:_____________________________ FAX:_________________________________ E-MAIL:__________________________________________________________________ TITLE OF COURSE:________________________________________________________ _________________________________________________________________________ DATE(S) OF COURSE:______________________________________________________ LOCATION OF COURSE:____________________________________________________ SPONSOR OF COURSE:_____________________________________________________ SPONSOR’S ADDRESS:_____________________________________________________ SPONSOR’S PHONE:__________________ E-MAIL:_____________________________ _________________________________________________________________________ HAS THIS COURSE BEEN APPROVED FOR CLE CREDIT IN OTHER STATES? G NO G YES G Application Pending If yes, which state(s)?___________________________________ If so, which state(s)?____________________________________ On a separate sheet: 6. Indicate method of presentation of course (faculty in room with participants, CD, DVD, teleconference, webconference, online, etc.). 7. Indicate method of participation (group activity or self-study). 8. Describe how your attendance/completion of this program was verified by the sponsor (sign in sheet, course code, etc.). 9. Describe audience to which the course is directed and advertised (attorneys, CPAs , etc.). 10. Provide faculty name(s) and credentials, including educational background/degrees. (Note: The faculty must include at least one attorney in good standing who actively participates in the program.) I certify that all information contained in this application is true. 11. Indicate total hours of instruction for which you seek CLE credit (not including breaks, meals or introductions) in each of the applicable categories: Ethics and Professionalism, Skills, Law Practice Management, Areas of Professional Practice. (For example, 3 hours Skills.) _________________________________________________________________ SIGNATURE DATE 12. If seeking credit as a presenter, describe your participation (speaker, moderator, panel member) and indicate the sessions presented/sessions attended. If this course has been submitted for approval in another jurisdiction, you may not need to submit this application to the New York State CLE Board. Please refer to New York’s Approved Jurisdiction policy available on the CLE Web site at www.nycourts.gov/attorneys/cle. __________________________________________________________________________ IAapp/01-08 INCOMPLETE APPLICATIONS WILL BE RETURNED American LegalNet, Inc. www.FormsWorkflow.com