American Speech-Language-Hearing Association

CE Additional Offerings Form

Please fill out all required fields to add an offering(s) to an existing registered course. This form and cooperative fee payment (if applicable) is due at least 3 days prior to each offering start date. If this deadline is not met, you will need to appeal. Use the Continuing Education Board Appeal Request Form to submit your appeal letter.

* indicates required field.

Provider and Registered Course Information

Provider Code:*

Provider Name:*

Provider E-mail:*

My CE Provider Manager is:*

Course Title:*

Course Number:*


Additional Offering(s) to Registered Course

If your submission is a Cooperative Offering, a fee ($250 for 1st offering and $50 for each additional offering) is required. You can pay with a credit card by calling 800-498-2071 or check mailed to: Continuing Education, ASHA, P.O. Box 1160 #340, Rockville, MD 20849.

Additional Offering 1

Start Date (MM/DD/YYYY):*

End Date (MM/DD/YYYY):*

City (if applicable):

State (if applicable):

Country (if applicable):

Is this a Cooperative Offering?*

Name of Cooperative Organization:

First Name of Contact at Cooperative Organization:

Last Name of Contact at Cooperative Organization:

Phone Number:

E-mail:

Additional Offering 2

Start Date (MM/DD/YYYY):

End Date (MM/DD/YYYY):

City (if applicable):

State (if applicable):

Country (if applicable):

Is this a Cooperative Offering?

Name of Cooperative Organization:

First Name of Contact at Cooperative Organization:

Last Name of Contact at Cooperative Organization:

Phone Number:

E-mail:

Additional Offering 3

Start Date (MM/DD/YYYY):

End Date (MM/DD/YYYY):

City (if applicable):

State (if applicable):

Country (if applicable):

Is this a Cooperative Offering?

Name of Cooperative Organization:

First Name of Contact at Cooperative Organization:

Last Name of Contact at Cooperative Organization:

Phone Number:

E-mail:

Additional Offering 4

Start Date (MM/DD/YYYY):

End Date (MM/DD/YYYY):

City (if applicable):

State (if applicable):

Country (if applicable):

Is this a Cooperative Offering?

Name of Cooperative Organization:

First Name of Contact at Cooperative Organization:

Last Name of Contact at Cooperative Organization:

Phone Number:

E-mail:

Additional Offering 5

Start Date (MM/DD/YYYY):

End Date (MM/DD/YYYY):

City (if applicable):

State (if applicable):

Country (if applicable):

Is this a Cooperative Offering?

Name of Cooperative Organization:

First Name of Contact at Cooperative Organization:

Last Name of Contact at Cooperative Organization:

Phone Number:

E-mail:

If you have more than five offerings to add, please submit this form and go to a new form to submit additional dates.

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