CEU APPLICATION FORM - $15 Fee
($20 for online processing)

CEUs for LCSW, LPC, and LCPC*

*Our CEUs are offered through the C. G. Jung Center in Evanston which is licensed to provide LCSW CEUs, which are also accepted by the LPC/LCPC licensing bodies in Missouri and Illinois.

*You may apply for a General Certificate of Attendance if you are licensed in another field.

Title of event(s): ______________________________________________

Presenter: ____________________________________________________

Date(s): ______________________________________________________

Number of CEU credits* for event(s): __________

*Consecutive events (lecture/workshop) credits may be combined on one form.

IMPORTANT: ALL fields must be completed in order to process your application!

!!!PROGRAM EVALUATION MUST BE COMPLETED AND SUBMITTED WITH CHECK!!!

- - - - - - - - - - - - - - - - - - - - - - - - - - - -Tear here for receipt- - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Date: ____________Number of CEUs: __________ Payment: __________ Check # __________

The C. G. Jung Society of St. Louis (314) 533-6809