Continuing Education Reporting Form for Submitting CE Credits Association of Surgical Technologists
Association of Surgical Technologists
6 West Dry Creek Circle • Suite 200 • Littleton, CO 80120-8031
NAME (TYPE OR PRINT ONLY)
CONTACT PHONE NUMBER
CERTIFICATION NUMBER
AST MEMBER NUMBER
STREET ADDRESS
E-MAIL ADDRESS
? CST ? CFA
CITY STATE ZIP CODE
EMPLOYER’S NAME
SOCIAL SECURITY NUMBER
XXX–XX–_______________
CURRENT CERTIFICATION CYCLE DATES
STEP 1
Month/Day/Year
[List in Chronological Order]
STEP 2
Name of the educational activity(All activities must be listed on the CE Reporting Form to receive credit.)
STEP 3
Provider name and location of CE activity
[Specify if activity was an in-service through your employer.]
STEP 4
# of credits
STEP 5
Copy of documentation enclosed [ ? ]
AST USE ONLY
1
2
3
4
5
6
7
8
9
10
STEP 6
I acknowledge that this is a true representation of CE credits earned.
Signature _________________________________ Date _____________
Total CE credits this page:
Total credits for this submission:
? Non-member $400 fee enclosed
ADD ALL REPORTING FORMS TOGETHER. DO NOT INCLUDE PREVIOUSLY SUBMITTED CE CREDITS
? CHECK ? VISA ? MASTERCARD ? AMEX CARD # _____________________________________ EXP. DATE _____________
AST USE ONLY: PC___ CD___ NA___ AP___ DN___ DUP___ XM___ FEE___ OT___ Total not accepted ______ Total approved ______
REV 11/09 OVER FOR INSTRUCTIONS q
