CTLE CERTIFICATION for PD with TBB

Please complete the following application if you wish to receive CTLE credit for the full day(s) of PD you attended with The Balance Between, Inc. Note that your personal information needs to be an IDENTICAL match to what the state has on file for you to get credit. You will receive 6 hours of PD credit for each full day session.

LAST NAME*

MIDDLE INITIAL

If the state has your middle initial, you MUST include this here.

FIRST NAME*

EMAIL*

DATE OF BIRTH*

LAST 4 SS #*

Enter the LAST FOUR digits of your Social Security number.

SCHOOL*

POSITION*

COHORT*

Identify the training event you participated in.

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COHORT DETAILS

If your cohort was NOT on the previous list, please tell us who you received PD from, when, and where so we can give you credit.

# of DAYS

How many full days of training did you complete as part of this course?

DAY 1

IF YOU ATTENDED THIS DAY, What was the date of this session? This must match the official sign in sheet. LEAVE BLANK IF YOU MISSED THIS DAY.

DAY 2

IF YOU ATTENDED THIS DAY, What was the date of this session? This must match the official sign in sheet. LEAVE BLANK IF YOU MISSED THIS DAY.

DAY 3

FOR TOT COURSES ONLY: IF YOU ATTENDED THIS DAY, What was the date of this session? This must match the official sign in sheet. LEAVE BLANK IF YOU MISSED THIS DAY.

DAY 4

FOR TOT COURSES ONLY: IF YOU ATTENDED THIS DAY, What was the date of this session? This must match the official sign in sheet. LEAVE BLANK IF YOU MISSED THIS DAY.

DAY 5

FOR TOT COURSES ONLY:IF YOU ATTENDED THIS DAY, What was the date of this session? This must match the official sign in sheet. LEAVE BLANK IF YOU MISSED THIS DAY.

DAY 6

FOR TOT COURSES ONLY: IF YOU ATTENDED THIS DAY, What was the date of this session? This must match the official sign in sheet. LEAVE BLANK IF YOU MISSED THIS DAY.

PARTICIPANT COMMENTS

Anything you need help with?

FEEDBACK

What was GREAT about this course?

FEEDBACK

What would you CHANGE about this course? What COULD BE BETTER?

PERMISSION

Can we share your feedback with others who would be inspired by your comments?

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