Recognized CPE Provider Application

Transcription

1 Recognized CPE Provider Application Please submit this application form and required course evidence to Along with this completed application form, you must submit all required course evidence outlined in the program standards or your application will be rejected. A sample of one facilitator-led: face-to-face, facilitator-led: electronic, self-directed study: paper-based, or self-directed study: electronic-based course must be submitted (where applicable). Please visit the following IIA webpage for a list of the program standards: If your application is received and approved between 1 January and 30 June, recognition will be granted from the date the application was approved until the end of the current CPE reporting calendar year. (For example, if your application is received on 3 March 2016 and approved on 17 March 2016, you will be granted Recognized CPE Provider status from 17 March 2016 until 31 December 2016.) If your application is received and approved between 1 July and 31 December, recognition will be granted only for the following CPE reporting calendar year. (For example, if your application is received on 20 September 2016 and approved on 5 October 2016, you will be granted Recognized CPE Provider status from 1 January 2017 until 31 December 2017.) Provider Information Name of Organization Physical Address Mailing Address Website Address Name of Designated Contact Telephone Number Address Name of Alternate Contact Telephone Number Address 1

2 1. Course Information (Facilitator-led: face-to-face; Facilitator-led: electronic; Self-directed study: paper-based; or Selfdirected Course Duration 2. Course Information (Facilitator led: face to face; Facilitator led: electronic; Self-directed study: paper-based; or Selfdirected 2

3 3. Course Information (Facilitator led: face to face; Facilitator led: electronic; Self-directed study: paper-based; or Selfdirected 3

4 4. Course Information (Facilitator led: face to face; Facilitator led: electronic; Self-directed study: paper-based; or Selfdirected 4

5 If applicable, list your NASBA Registry ID Terms and Conditions By signing this Recognized CPE Provider Application form, I agree to the following: 1. I certify that the statements in this Recognized CPE Provider Application form are true, correct, and complete to the best of my knowledge and belief, and understand that any false statement is sufficient cause for rejection of this application or, if a Recognized CPE Provider Seal has been awarded, for the termination of the Seal. 2. I agree that if a Recognized CPE Provider Seal is awarded on the basis of this application, I will comply with the applicable terms, conditions, and procedures of The Institute of Internal Auditors, Inc. 3. I agree that The Institute of Internal Auditors, Inc. may make whatever inquires and investigations to verify the accuracy of information that I provide in this Recognized CPE Provider Application form or may have it verified by third parties. 4. I agree to indemnify, defend, and hold harmless The Institute of Internal Auditors, Inc., its officers, directors, partners, and employees from and against any and all demands, claims, causes of action, damages, costs, and expenses (including reasonable attorneys fees) resulting from my act, omission, or negligence arising out of (directly or indirectly) with this application, the application process, the denial or withdrawal of the Recognized CPE Provider Seal, or changes in eligibility for approval. I agree that The Institute of Internal Auditors, Inc. liability for all claims, losses, liabilities, or damages arising from or in connection with this application will be limited to the total fees I have paid. 5. I agree that I am required to submit a non refundable application fee in order to process this application. 6. I agree that The Institute of Internal Auditors, Inc. may refuse to approve this application for any reason or no reason. I understand that the decision as to whether I qualify for the Recognized CPE Provider program rests solely and exclusively with The Institute of Internal Auditors, Inc. 7. Your signature assures that all of the information that you provided in this Recognized CPE Provider Application form is complete and true. Provider Authorized Signature Title Print Name Today s Date 5