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CEC Summary Form for Certification Renewal

Name:
Phone:	Email:
MEMBER USE – PLEASE TYPE OR PRINT NEATLY	OFFICE USE ONLY
Event Title & Provider	Event Date(s) (mm/dd/yy)	# of hours	# Credits	Expiry Date	Year Used

PLEASE ATTACH

• Description of event and how it applies to your certification – Brochure, transcript, and poster are acceptable.

• Proof of registration or completion of training – Receipt or certificate of completion.

Note:

• Credits are valid for 27 months after the date of the event.

• To be applied, credits must fall within the two year time frame of the due date on your renewal form.

(ie: If your credits are due March 31, 2013, they will be honored with expiry dates between April 1st 2011 and March 31st, 2013.)

Please forward completed form and proof of workshop registration by:

E-mail: membershipservices@fitnessnb.ca Fax: (506) 453-1099

Mail: Fitness NB

A112A Lady Beaverbrook Gym, 2 Peter Kelly Drive,

University of New Brunswick, PO Box 4400, E3B 5A3

Telephone:(506) 453-1094