AMBA CEU Submission Form

Date_______________________

First Name ________________________________Last Name ____________________________MI __________

Business Name______________________________________________________________________________

Address ____________________________________________________________________________________

City _________________________________________________ST __________________Zip________________

Wk Phone ________________________Home Phone ______________________Fax______________________

Email Address_______________________________________________________________________________

AMBA Membership #____________________    CMRS Anniversary Date______________________

List CEUs

CEU Date

CEU Instructor/Publisher

CEU Hours

Is it AMBA Pre-Approved?

Note to Members - It is your responsibility to submit this form.  Please include any proof that CEUs were obtained, such as a certificate of completion, proof of purchase, invoice, etc.....  Please do not submit original documents, because they will not be returned.  All 15 CEUs must be submitted together on one form. Effective Jan. 1, 2008, fifty (50) percent of CEUs must come from AMBA courses and or training.

Please do not fax if more than 10 pages.

Mail to:          AMBA

                       4297 Forrest Drive

                       Sulphur, OK 73086