Florida Environmental Health Professionals' Registration Board Continuing Education Submission Form - Print this page and mail it in (see below).

Name Date:

Mailing Address

City State Zip

Check here if this is a new mailing address

Work Phone: Home Phone:

Name of Course or Training:

Date of Training: To: Total Contact Hours of Training *:

Training Provided By:

I Certify That I Completed The Contact Hours of Training Listed Above:

Signature: __________________________________, R.S.

Email Address :

Witness: , R.S.

Printed name of witness:

A. If a witness who is registered is not available, you must submit a certificate of completion, registration fee receipt or other evidence of attendance.
B. Please submit an agenda, program outline or summary of the course.
C. Retain a copy of items submitted for your file.

*A contact hour is equal to one hour of actual time spent in continuing education. Each contact hour must be under responsible sponsorship, capable direction and qualified instruction. Breaks, meals and other time spent outside the formal training cannot be counted as contact hours.

Print and Mail this Form to:

Herrose@bellsouth.net
8044 Princess Palm Cir
Tamarac, Florida 33321
(954) 720-5803