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hcpinfo@arizona.edu

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THE UNIVERSITY OF ARIZONA HEALTHCARE PARTNERSHIP NICOTINE DEPENDENCE TREATMENT CONTINUING EDUCATION & CERTIFICATION PROGRAMS

Notice of Program Form

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Planning Your Program

The University of Arizona HealthCare Partnership requests this Notification Form at least 10 working days before a class is scheduled to allow time for processing and shipping.

"*" indicates required fields

Certification Information

Certification Date*

Month

Day

Year

Please choose the certification date.

Certification Time*

Hours

:

Minutes

AM/PM

Time Zone*

Intended Audience/Organization*

What types of health advocates or specific organizations do you intend to reach at this workshop?

Certification Location Type

In-person

Virtual

Please let us know if the certification location is in-person or virtual.

Certification Location*

Street Address Address Line 2 City State ZIP Code

Certification Type*

Open

Closed

Instructor Name*

First Last

Instructor Email*

Shipping Address

Business Name*

Business Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Fax

Program Information

Which program will you be teaching?*

Native Communities

INSTRUCTOR Native Communities

Maternal and Child Health

INSTRUCTOR Maternal and Child Health

Medical and Allied Health Professionals

INSTRUCTOR Medical and Allied Health Professionals

Instructional Specialist

Treatment Specialist

INSTRUCTOR Treatment Specialist

Expected Number of Attendees*

Please enter a number greater than or equal to 1.

Names of Certification Candidates

Name	Actions

There are no Candidates.

Maximum number of candidates reached.

Notes/Comments

I have previously instructed The University of Arizona HealthCare Partnership continuing education/certification program.*

Yes

No

Comments

This field is for validation purposes and should be left unchanged.

HealthCare Partnership

PO Box 210151
1717 E. Speedway Blvd., Suite 3106
Tucson, AZ 85721-0151

Phone: 520-626-9344 Fax: 520-626-9355 Email: hcpinfo@arizona.edu

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