APPLICATION FOR CONTINUING MEDICAL EDUCATION COLLABORATION

APPLICATION FOR CONTINUING MEDICAL EDUCATION (CME) ACCREDITATION

CME PHARMACEUTICAL/OTHER COMPANY ORGANIZER DETAILS:

Organization Name:

Address:

Email Address:

Tel No.:

Contact Telephone No.:

ACTIVITY DETAILS:

Date of Activity:

Location of CME Activity (Hybrid/Virtual/Venue):

Duration of Activity:

Co-Organizer Details:

Section

• Representative Name:

• Representative Email:

•Representative Telephone No.:

Title of Programme/Activity:

Outline of Day’s Activities (Attach Document):

Programme Goals and Objectives (Attach Document):

EDUCATIONAL METHODOLOGY:

Description of Educational Methodology to be Used:

EVALUATION AND ACCREDITATION DETAILS:

Method of Programme Evaluation:

Credit Hours Proposed by CME Pharmaceutical/other organization:

SCOPE OF COLLABORATION (Please indicate required services by checking the appropriate box):

Accreditation Support
IT Support for Hybrid or Virtual Events
Distribution of CME Certificates
Designing of Promotional Flyers
Provision of Zoom Platform
Advertising and Promotion of Event
Design of CME Certificate
Provision of Post-Event Report (Attendee Report & Copies of CME Certificates)

SUBMISSION OF REQUIRED DOCUMENTS: Partners must submit the following documents to facilitate the application process:

Event Agenda
Speaker Bios
Programme Objectives
Other Supporting Documents as Necessary

AUTHORIZATION: I, the undersigned, confirm that the information provided is accurate and that the required documents will be/is submitted on this platform as part of this application.

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Name of CME Medical Organizer Representative:

Date:

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