For Board Use Only Received_______________ Proposal No.____________ __Approved __Not Approved Date of Action___________

PROGRAM  PRE-APPROVAL FORM A person seeking to obtain pre-approval of a continuing education program shall complete and submit this form at least thirty (30) calendar days in advance of program to the Louisiana State Board of Architectural Examiners ("Board"), 9625 Fenway Avenue, Suite B, Baton Rouge, LA 70809, Phone:  (225) 925-4802;  Fax:  (225) 925-4804 for consideration by the Board.  Upon review by the Continuing Education Committee, you will be notified of the Board's decision. 1. Program Sponsor: Name:______________________________ Contact Person: _________________________ Address: ________________________________________ Phone Number: __________________ FAX Number: ________________ 2. Program Description: Name and detailed description of subject matter and program offering. Classify specific topic as to subject matter shown on Louisiana State Board of Architectural Examiners list of Approved Seminar Topics. If additional space is needed, please attach separate sheet. ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Length of instructional periods: _________________________________________ 3. Program Instructor(s)/Leader(s): Names of instructor(s)/leader(s). Please include educational and professional credentials. ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ 4. Time, Place, Date and Location of Program: Time: ______________ Place: __________________________________ Date: ______________ Location: __________________________________ Based on the above information,__________________________________ CEH's are requested.   __________________________________ (Signature and Title) __________________________________ (Date)         Upon review by the Continuing Education Committee of the Louisiana State Board of Architectural Examiners, ________ CEH's have been approved. __________________________________ Mary "Teeny" Simmons, Executive Director __________________________________ (Date)