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Submitted by: __________________________________________________________________
State: ________________________________________________________________________
List course/lecture/article/video/title: _______________________________________________
Presented by: __________________________________________________________________
Date Complete: _____/______/______
Location:______________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
The above information is accurate and true to the best of my knowledge:
Signature: _________________________________
Date: ______/______/______
Certified remotivation therapist since: ______/______/______
1 hour = 60 minutes of classroom time, video running time, lecturer time or time assigned to an article in The Remotivator newsletter or articles that may be recommended in The Remotivator.
Presented by (Include credentials such as M.A., Ph.D., CRmT, MD, etc.):
_____________________________________________________________________________
Date completed (date activity occurred): ______/______/______
Location: Where the continuing education took place and/or sponsor of continuing education.
Remotivation recertification was authorized by the Board of Directors, National Remotivation Therapy Organization on October 31, 1996. Fifteen (15) hours of continuing education must be taken by all remotivation therapists every two years.
_________________________________________________________________________
OFFICE USE: Last dues received: ___________.
Total acceptable hours: ___________.
Require explanation on #________________.
Recertification is granted __________ is not granted __________. Explanation of refusal attached.
Signature of evaluator: ___________________________________
Date: _____/_____/_____