CME Application (Form A)

Submitted by:
E-mail:

CME Topic:
Target Audience:
Expected Attendance:
Is this a Medical Staff Meeting? or Stand-alone Presentation?
Date and Time of Activity:
If this is a recurring program, you must fill out a CME Application for each date and location.
Location:
Length of Presentation:
One CME hour equals 60 minutes of activity and each 15 minutes equals .25 credits
Type of Presentation:
Lecture, workshop, symposium, etc.
Faculty/Speaker(s):