PART II
(CEHR-H completes Part II and forwards to proponent)
1. PROPOSED COURSE TITLE
2. CEHR-H CONTROL NUMBER
3. IDENTIFICATION OF PROPONENT ORGANIZATION (Include point of contact and telephone number)
7. COMMENTS
NAME AND TITLE (Type or Print)
SIGNATURE
TELEPHONE NO. (Incl. Area Code)
DATE
(ENG FORM 4713-R)
Page 2 of 4 Pages