IFC INTERNATIONAL

CONTINUING EDUCATION PROGRAM COMPLETION FORM
COUNSELOR INFORMATION
*Counselor's First Name and Last Name:**
*Certificate Number :**
*Certificate Designation:**
*Counselor Type:**	Independent Counselor Employee
*Agency Name:**
CONTINUING EDUCATION COURSE INFORMATION
*CEU Course Title:**
Number Of CEUs*:
Date Completed*:
CONTACT INFORMATION OF COUNSELOR
*Address Line 1 :**
Address Line 2:
*City :**
*Zip Code :**
*State :**
Country :
*Email-Address:**
*Phone Number :**
Report to South Carolina Dept of Consumer Affairs*:
*DL Number for Reporting::**