2003 Namss Seminar Request Forms

2003 Namss Seminar Request Forms

CERTIFICATION PREPARATIONCOURSES

STATE APPLICATION OF INTEREST FOR JOINT SPONSORSHIP

Please complete this application of interest to organize NAMSS Certification Preparation Courses in your area and return to the address belowat least three months prior to when you would like to host the course. Once submitted, this application will be reviewed by the NAMSS Education Committee. Courses will be scheduled based on order of receipt and instructor availability within two weeks of receiving the application.

State Organization: ______

Contact Name: ______

Contact Email: ______

Phone: ______Fax: ______

Complete Mailing Address for Organization:______

______

Credentialing Specialist (CPCS) Certification Preparation Courseand Medical Services Management (CPMSM) Certification Preparation Courses

Please check the following boxes, sign and date the form below to acknowledge pre-requirements for jointlysponsored NAMSS Certification Preparation Courses.

State Organization agrees to 2-Day Certification Preparation Course educational model.

State Organization agrees to pay NAMSS the following fees:

  • $1,000 Licensing Fee to NAMSS per course offered
  • $100 course material fee (per participant)
  • $1,500 Instructor honorarium (per instructor)
  • 26 + students must have two instructors

Requirements for Consideration:

State Organization agrees to have a minimum of 35 registrants for the CPCS Certification Preparation Course and 25 registrants for the CPMSM Certification Preparation Course (not required to host both courses).

(Preparation Course is subject to cancellation if registration does not meet minimum number of participants.)

State Organization will cover costs of lodging, per diem and travel to/from course location for NAMSS Instructor(s).

State Organization agrees not to host a competing course in the region within six months from the scheduled course date.

NAMSS Instructors will be scheduled and confirmed by NAMSS, based on availability. State Organization can make requests which will be honored whenever possible.

State Organization agrees to designate an On-Site Coordinator who will:

  • Manage facility logistics, registration, and Audio-Visual materials needed for course and assume all expenses associated with course logistics, registration and Audio-Visual;
  • Provide one laptop, LCD projector, screen and two flip charts for course meeting room;
  • Serve as the on-site liaison to NAMSS Instructor(s) and registered participants;
  • Check in participants.

Provide volunteers to serve as room monitors to assist the instructors during the course.

Preferred Dates for hosting Certification Preparation Courses: ______

By signing and returning this Application of Interest to NAMSS, I signify that the organization, ______, understands and agrees to all the pre-requirements as written.

______

Name Date

Please note that submitting an application is not a guarantee the course will be scheduled in your area.

State sponsored course dates and locations will be announced two weeksfollowing receipt of this application by the NAMSS Education Committee. Please return this form to:

NAMSS

2025 M Street, NW Suite 800

Washington, DC20036

PHONE: 202-367-1196

FAX: 202-367-2116

Thank you for submitting your application!

State Organization Course Application of Interest v2

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