New York State Continuing Legal Education Board 25 Beaver Street, Room 888, New York, NY 10004 Phone: (212) 428-2105 • Fax: (212) 428-2974 • E-mail: cle@ courts.state.ny.us W eb site: w w w .nycourts.gov/attorneys/cle 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, include all required attachments (items 1 - 6) and respond to items 7-11. 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 m ust be postm arked within 30 days of the com pletion of the course or program . See New York State CLE Board Regulations and Guidelines § 8(A)(3)(b). NAME OF ATTORNEY REQUESTING CREDIT: ________________________________________________________________________ YEAR ADMITTED IN NEW YORK: __________________________________________________________________________________ MAILING ADDRESS: ______________________________________________________________________________________________ CITY: ______________________________________ STATE: ____________________________ ZIP:____________________________ 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? [ ] NO [ ] YES [ ] Application Pending If yes, which state(s)?__________________________________________________________________________ If so, which state(s)?___________________________________________________________________________ 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. REQUIRED ATTACHMENTS in support of your application: 1. BROCHURE - Attach a brochure, advertisement or announcement for the course (if not available, attach a course description). 2. AGENDA - Attach final version of the timed agenda or timed outline of course (if multiple sessions, indicate sessions attended). 3. ETHICS CREDIT - Clearly indicate on the timed agenda/outline all session(s) for which you seek CLE credit in Ethics and Professionalism. 4. PROOF OF ATTENDANCE - 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.) 5. WRITTEN MATERIALS - 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. 6. FACULTY BIOGRAPHIES - Attach a biography for each faculty member. It should include educational background and degrees earned. (Note: The faculty must include at least one attorney in good standing who actively participates in the program.) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com NAME OF ATTORNEY REQUESTING CREDIT: ________________________________________________________________________ 7. Indicate method of presentation of course (faculty in room with participants, CD, DVD, teleconference, webconference, online, etc.). 8. Indicate method of participation (group activity or self-study). 9. Describe how your attendance/completion of this program was verified by the sponsor (sign in sheet, course code, etc.). 10. Describe audience to which the course is directed and advertised (attorneys, CPAs , etc.). 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.) 12. If seeking credit as a presenter, describe your participation (speaker, moderator, panel member) and indicate the sessions presented/sessions attended. Please check to see you have responded to all items. INCOMPLETE APPLICATIONS WILL BE RETURNED. I certify that all information contained in this application is true. __________________________________________________________________ SIGNATURE DATE R evised 6/2011 N ew Y ork State C LE Board - Individual Attorney Application Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com