CONTINUING EDUCATION UNITS EXTENSION
AND/OR TRANSCRIPT REQUEST FORM

Per section 13 of the CCR Program, if you fail to meet the continuing education credit requirement of 2.0 CEUs in a two-year cycle, you may submit a written request for a three-month extension to obtain the required CEUs. The extension will be allowed only upon a written request to and approval by the Board. It will be the individual’s responsibility to contact the Board and show good cause to support their request of an extension.  The Board must receive the extension request before the CCR term expires on June 30th.  If the extension is granted by the Board, the CCR will have three months from the date the extension was granted to accumulate the 2.0 CEUs needed for their current term.  Once the 2.0 requirement has been met in that three-month period, the CCR will begin a new two-year cycle, which will expire on June 30th two years later, thus giving the CCR a shorter time period to earn the 2.0 CEU requirement for the new term.

There is a $25 extension/processing fee, which should accompany your request.  All appeals must be in writing.  You will be notified of the outcome of your appeal in writing shortly after the board votes on your request.  After a notice of noncompliance has been issued, if the CCR Committee does not receive an extension request from the CCR, you will receive a letter revoking your certificate.  See Section 12: NULLIFICATION, REVOCATION OR SUSPENSION OF CERTIFICATE for information regarding a certificate that has become null and void.

REQUEST FOR THREE-MONTH EXTENSION

I would like to request an extension of three months in order to complete my CEU requirements.  In doing so, I understand that all CEUs earned during this period will be entered in my record as earned in the current cycle.  CEUs earned above the required amount may not be carried forward to the next cycle.

Reporter Signature: _________________________________ Date: ___________

CCR Committee ________________________  Approved____ Declined____ Date: ____

This form must accompany a formal written request to the board for a three-month extension, as outlined in Section 13 of the CCR Program, along with a $25 processing fee.

CEU TRANSCRIPT REQUEST

NAME: _________________________________________  CCR#______________

E-mail Address: _______________________________ Phone Number: _____________

Mailing Address:_____________________________________________

City: _______________________  State: ___________  Zip Code: __________

Return this form to TCRA, CCR Committee, P.O. Box 135, Brunswick, TN 38014.

Revised May 2005

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