Sponsor Annual Report |

Organization Name*
Sponsor Number*
Official Contact*
First Last
Address
Street Address City State ZIP Code
Phone*
Fax
Email*
Section Break
Sponsor Organization Renewal Date
MM slash DD slash YYYY
Total Number of CE Sessions Held
Total Number of CE Hours (PDH) Awarded
Total Number of Attendees
Review of Continuing Education Activities
Please use this space to describe any problems or concerns you have encountered in executing your continuing education program during this past year
Required Supporting Documentation for Renewal :

A) Attach an index of all approved courses in your program and all sessions held in the last reporting year. Include the course name, as well as the number assigned to it, number of PDH’s approved for it, date and location of each session, and indicate whether or not the associated file is complete (attendance sheets are in, certificates have been distributed, and that the speaker’s resume, the course materials and all associated documents are included in said file.)

B) Attach a list of PIE Approved Evaluator’s being utilized to evaluate programs for your organization.

NOTE: Follow the link on the confirmation page to submit documents

I, the undersigned, hereby certify that the information requested on this form has been provided as truthfully and accurately as is possible:
Signature*
First Last
Date*
MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.

Sponsor Annual Report