National Institute for Excellence in Professional Education, LLC

Continuing Education Reporting Form


Last Name:
First Name:
Middle Initial:

Company Name:
Business Address:
City:
State:
Zip:
Business Phone:
Business Fax:
Email Address:

Program:
Year of Completion:

Date Completed (mm/yy)	Course Name	Course Sponsor	Format	Credit Hours Awarded










Total Credit Hours Earned:

Affidavit: I attest to the truth and accuracy of all statements in this affadavit. (please initial)

Important Note: Do not send supporting documentation unless requested. However, supporting documentation should be retained in your files for a minimum of two years following the end of the reporting period.

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National Institute for Excellence in Professional Education (NIEPE)
237 Lancaster Avenue
Suite 7500
Devon, PA 19333
(610) 688-4574