California BBS CEU Application for LMFTs and LCSWs

Full Name: *
MFT or LCSW:		License#:
Address:		City:
State:		Zip:
Phone:		Email Address: *
Event Title:		Event Dates You Attended:
Payment Information: This is a secure form and site. Your information will not be used other than to process your payment and CEU Certificate. CEU fee: $25
Type of Credit Card: drop box:	Visa MC Discover AmEx	Credit Card Number:
Expiration:		VIN Number: on the back of the card
Information is same as above
Name on card: *
Billing Address:		City:
State:		Zip:
The charge will be put through and your certificate will be emailed to you as an attachment after sign-in verification of your hours. Your charge card statement will show the $25 charge as IMAGINALWAYS PAYPAL PMENT. If you do not attend the event, you will not be charged and you will not receive a certificate. Please contact our California BBS CEU Provider with any questions related to CEUs for LMFTs and LCSWs: Cynthia Anne Hale, PhD, LCSW, BBS; CA Provider #PCE 3940. CynthiaHale@imaginalways.com * Required Fields