Course Sponsor Prior Approval

Dry Needling Course Sponsor Prior Approval

Please Note: This form is only for use with an online payment.
If you do NOT plan to pay online, do not use this form. Fill out the paper form and mail it with your payment.

*Required Fields
*1. Course Title:
*Date(s):
*Duration (hours):
*2. Location(s)
*3. Sponsoring Organization:
*Address:
*City:
*State:
*Zip:
*4. Course Instructor(s):
*5. Course Instructor Background Information (i.e. education, employment, publications, and instruction experience ) Upload resume or CV:
*6. Course Agenda/Instructional Timeline:
*7. Course Objectives:
*8. Course Description/Overview:
*9. Sample Copy of Certificate of Completion:
*10. Please indicate if this continuing competence activity has been approved for credit by any professional organizations. (please list)
11. Please give a name, address and phone number of a contact person who can provide information concerning this activity.
*Name
*Address
Address 2
*City
*State
*Zip
*Phone
*Email
Any information, forms and brochures that are required can be uploaded by being combined into 1 PDF that is not more than 5Mbs. If your PDF is larger than this please email or mail to the board office address below.
This form is to be used for the approval of dry needling credentialing only and not for CC approval.

When you submit this form you will be taken to the payment screen. If you have any questions regarding this form, you may call 601-352-2918.