Joint Providership Inquiry Form

Organization Name:*

Is this organization's primary business producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients?*

Yes*No

*If yes, the organization is not eligible to participate in Joint Providership of CME.

Primary contact person:*

Email Address*

example@example.com

Phone Number*

Area CodePhone Number

Describe your organization and its mission:*

Title of Proposed Activity:*

In what state will this meeting be held?

If outside the U.S., please indicate location:

About how many learners do you anticipate will participate in this activity?*

Start Date of Activity:*

Date

End Date of Activity*

Date

Anticipated Number of CME Credits (hours):*

Check the box that best describes the FORMAT of the planned CME Activity:*

1-hour presentation1-day conference with multiple sessions2-3 day conference with multiple sessionsOngoing series of sessions (Tumor Board, CaseConference, etc.)

Please share anything else you think we need to know about this activity:

Completion of this document is not a guarantee that the MDCMA will jointly provide this activity with your organization. MDCMA staff will contact you to discuss the possibility of joint providership with the MDCMA.