New York State Continuing Legal Education Board 25 Beaver Street, Room 888, New York, NY 10004 • Phone: (212) 428-2105 Fax: (212) 428-2974 • W eb site: www.nycourts.gov/attorneys/cle • E-m ail: cle@ courts.state.ny.us APPLICATION FOR ACCREDITED PROVIDER STATUS SPONSORING ORGANIZATION:______________________________________________ __________________________________________________________________________ ADDRESS:________________________________________________________________ __________________________________________________________________________ REQUIRED ATTACHMENTS: Please submit an original and one copy* of the completed application and supporting materials. (Incomplete applications will be returned.) For THREE COURSES, one from each of the preceding three years, please submit the following information: PHONE:_____________________________ FAX:_________________________________ E-MAIL:___________________________________________________________________ NAME AND TITLE OF CONTACT PERSON:____________________________________ __________________________________________________________________________ NUMBER OF CLE COURSES SPONSORED, ORGANIZED AND ADMINISTERED BY YOUR ORGANIZATION DURING THE PAST THREE YEARS:_____________________ PLEASE DESCRIBE THE CONTINUING LEGAL EDUCATION ACTIVITIES OF YOUR ORGANIZATION OVER THE PAST THREE YEARS, AND ATTACH A LIST OF ALL CLE COURSES PRESENTED BY YOUR ORGANIZATION DURING THAT TIME, INCLUDING THE TITLE, DATE, LOCATION AND FACULTY FOR EACH COURSE, INDICATING WHICH FACULTY MEMBERS, IF ANY, ARE ATTORNEYS: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ DOES YOUR ORGANIZATION PLAN TO OFFER COURSES IN NEW YORK DURING THE NEXT YEAR? 9 YES 9 NO _ PLEASE DESCRIBE YOUR ORGANIZATION’S FINANCIAL AID POLICY AND PROCEDURES. INCLUDE THE SPECIFIC APPLICATION PROCEDURES AND THE ELIGIBILITY REQUIREMENTS FOR SUCH AID. PROVIDER APPLICATIONS THAT DO NOT INCLUDE A FINANCIAL AID POLICY FOR COURSES OFFERED FOR A FEE ARE INELIGIBLE FOR CLE BOARD REVIEW. (ATTACH ADDITIONAL SHEETS IF NECESSARY): __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ LIST OTHER STATES GRANTING OR DENYING ACCREDITED PROVIDER STATUS AND INCLUDE SUPPORTING DOCUMENTATION WHERE APPLICABLE: 9 title of each course 9 date(s) and location(s) of course 9 registration fee 9 timed agenda or timed outline of course 9 brochure or advertisement (if not available, provide course description) 9 faculty name(s) and credentials, including educational background/degrees 9 complete set of written materials distributed for the course 9 total hours of CLE instruction (based on a 50-minute hour, not including breaks, meals or introductions) 9 breakdown of CLE credit hours into the applicable categories: Ethics and Professionalism, Skills, Law Practice Management, Areas of Professional Practice 9 audience to which the course was directed and advertised 9 admission restrictions, if any 9 description of method of evaluating the course (participant critique, independent evaluation, etc.) 9 method of presentation (faculty in room with participants, audiotape, videotape, CD-ROM, video replay, teleconference, online, etc.) 9 attendance verification procedures for each format 9 sample of each nontraditional format (audiotape, CD, videotape, online access, etc.) __________________________________________________________________________ Provider acknowledges and agrees to comply with all Program Rules and CLE Board Regulations and Guidelines, and certifies that the above information (including all attachments) is true. __________________________________________________________________________ PROVIDER REPRESENTATIVE AND TITLE __________________________________________________________________________ SIGNATURE * You may be required to submit up to four (4) additional copies. DATE Apapp/11-05 American LegalNet, Inc. www.USCourtForms.com