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Continuing Education Petition Application for NASM CPT Please complete this form to request approval for continuing education courses that are not pre-approved by NASM-BOC. Contact Information First Name Last Name Mailing Address City State Zip Code Daytime Phone Evening Phone E-mail CEU Information Course/CEU Activity Title Type of Activity Workshop Seminar Date s Home study Conference Other Contact Hours excluding scheduled breaks Course/CEU Provider Phone Number Web Site Payment of Petition Fee 25 non-refundable petition fee for EACH course petitioned Visa MasterCard Check/Money Order payable to NASM American Express Card Number Expiration Date Name on Card Security Code Signature All continuing education approved to recertify any NASM credential must directly represent the performance domains published in the most current edition of the Job Analysis Study. Continuing Education Petition Application for NASM CPT Please complete this form to request approval for continuing education courses that are not pre-approved by NASM-BOC. Contact Information First Name Last Name Mailing Address City State Zip Code Daytime Phone Evening Phone E-mail CEU Information Course/CEU Activity Title Type of Activity Workshop Seminar Date s Home study Conference Other Contact Hours excluding scheduled breaks Course/CEU Provider Phone Number Web Site Payment of Petition Fee 25 non-refundable petition fee for EACH course petitioned Visa MasterCard Check/Money Order payable to NASM American Express Card Number Expiration Date Name on Card Security Code Signature All continuing education approved to recertify any NASM credential must directly represent the performance domains published in the most current edition of the Job Analysis Study. Please answer the following questions in addition to supplying the required information and documentation* This continuing education course falls under which Performance Domain s check all that apply Assessment Exercise Technique Program Design Nutrition Client Relations Administration Professional Practice Responsibility How has this course workshop or educational product provided knowledge skill and ability above entry-level Complete the NASM Continuing Education Petition Application Make a copy of all information for each course as follows Certificate of Completion Course outline or agenda Instructor resume or bio Course objectives Referenced text material if applicable Include check or credit-card information Mail all items to NASM BOC 1750 E Northrop Blvd. Suite 200 Chandler AZ 85286 Allow 30 days for processing of our application* Incomplete applications will be returned for resubmission* If you have questions about recertification please contact the NASM-BOC at 800. 460. 6276 Option 3. Complete this form only if you need to petition a course that is not approved by NASM-BOC. Contact Information First Name Last Name Mailing Address City State Zip Code Daytime Phone Evening Phone E-mail CEU Information Course/CEU Activity Title Type of Activity Workshop Seminar Date s Home study Conference Other Contact Hours excluding scheduled breaks Course/CEU Provider Phone Number Web Site Payment of Petition Fee 25 non-refundable petition fee for EACH course petitioned Visa MasterCard Check/Money Order payable to NASM American Express Card Number Expiration Date Name on Card Security Code Signature All continuing education approved to recertify any NASM credential must directly represent the performance domains published in the most current edition of the Job Analysis Study. Please answer the following questions in addition to supplying the required information and documentation* This continuing education course falls under which Performance Domain s check all that apply Assessment Exercise Technique Program Design Nutrition Client Relations Administration Professional Practice Responsibility How has this course workshop or educational product provided knowledge skill and ability above entry-level Complete the NASM Continuing Education Petition Application Make a copy of all information for each course as follows Certificate of Completion Course outline or agenda Instructor resume or bio Course objectives Referenced text material if applicable Include check or credit-card information Mail all items to NASM BOC 1750 E Northrop Blvd.