Response

Department of Crime Victim Services

Training, Provider Certification, and Statistical Analysis

Non-Accredited Certification Request

Each Victim Service Provider (VSP) who attends a training that was not submitted to CVST for accreditation by the sponsor must submit this completed request within 30 days after attending training in order to be considered for continuing education credit.

First Name

Last Name

Organization

Address Line 1

City

State

Zip

Phone

VSP Number

Training Sponsor / Organization:

Title of Training:

Location of Training:

Program Date(s):

Proper documentation *must* be included:
- Proof of attendance (example: certificate of completion)
- Detailed training agenda - to determine eligible hour(s)
- Course outline/description - to determine eligible course(s)
- Training brochure or other documentation

** If the training included concurrent sessions, you must indicate which session(s) were attended in your attached documentation.

Proof of Attendance (Certificate of completion)

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Detailed Training Agenda (Including dates and times of training sessions)

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Additional documentation (Course descriptions, registration information, etc.)

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Additional documentation (Course descriptions, registration information, etc.)

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Additional documentation (Course descriptions, registration information, etc.)

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Please print this page for your records prior to submission.