CME Program Announcement Request Form

CME PROGRAM ANNOUNCEMENT REQUEST FORM

Constituent organizations and PA programs may submit conference information for the AAPA CME calendar and for posting on the AAPA website free of charge. All other organizations must receive AAPA CME approval and pay a listing fee prior to listing on the AAPA CME Calendar. If the event has been approved for AAPA Category I CME, the number of hours will be included in the listing.

Meeting Information for AAPA Website and Publications:

Meeting Start Date:

Meeting End Date:

Program Title:

Meeting Description:

0/999 characters

Provider (full name no acronyms):

Meeting Location:

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Will this program occur within 250 miles and six months (preceding or following) any of these AAPA Annual PA Conference? Both qualifiers must apply in order to check the Yes box.

Toronto, May 26-31, 2012
Washington DC, May 25-30, 2013

Yes

No

Meeting Contact Information:

First Name:

Last Name:

Phone Number:

E-Mail Address:

Website for More Information:

Link to Register:

From which of the following organizations will you be applying for CME/CE credit? Check all that apply.

Contact Information for the Submitting Person:
This contact information is for internal use only and will not be part of the listing.

First Name:

Last Name:

Phone Number:

E-Mail Address:

Educational Grants:
Contact AAPA for instructions prior to requesting any educational grants to support this program.

List any commercial organizations that may be asked to support this conference:

Applications for conferences are due 4-6 weeks in advance. Information contained on any linked sites may not be in conflict with the mission of AAPA. If you have any questions, please contact AAPA at 703-836-2272 ext. 3417.

AAPA	AOA	ACPE	AMA
ANCC	AAFP	One of the ACCME sponsors	Other (please specify)