Name of Organization:

Organization Type:   Non Profit     Proprietary

Hospital
Educational General
Voluntary Health Agency
Educational Medicine
Rehabilitation Center
Government Agency/Division
Clinic or Ambulatory Center
HMO
Insurance Carrier
Pharmaceutical/Medical Device Manufacturing Company
    
Other - Specify  

Address:

City, State, ZIP:

Chief Executive Officer:

Only complete the sections that apply to your organization:

 

DME or Individual Responsible for Education:

Telephone:

Number of Educational Programs Conducted Each Year:

Total Number of Physician Education Hours Each Year:

Number of Category 1 CME Hours Each Year:

Are you approved by ACCME or MSNJ to sponsor AMA/PRA CME?

Person Completing this Form:

Telephone:   

Fax Number: