Request for Continuing Education Credit Form

Submitted by JCAttamack on Tue, 04/08/2025 - 12:19

Please complete this form to request continuing education credit.

Include with this form:

Proof of attendance (certificate listing total hours earned, or pre- approved group sign-in sheet).
If submitting documentation for attending at least 75% of professional meetings (Chap 27 .0820) also include the schedule of meetings for the year and proof of which meetings were attended.

Send attachments by email or mail:

Email: bryan.colvard@dhhs.nc.gov and casey.champion@dhhs.nc.gov
Mail: NC Well Contractors Certification Commission, 1653 Mail Service Center, 5605 Six Forks Road, Raleigh, NC 27699-1653

Indicates required field

First name

Last name

Address

Address 2

City/Town

State

ZIP Code

Email address

Phone

Well contractor certification number

NCWC

Applicant is:

Course attendee

Course instructor/provider

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