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?

*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:

What type of activity will this be?:

Other

If you selected "other" please explain:

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:

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.