Clone of AOA Attestation Form for CME Credit

ACCME Accreditation Form for CME Credit

AMA PRA Category 1 Credits™
CME participant records will be maintained by the Office of Continuing Medical Education (CME) for a period of six (6) years. Separate files containing all of the program information will also be kept by the Office of CME.

At the conclusion of the program, participants should complete and return the following form for credit to be requested from the ACCME.
Full Name*

First NameLast Name
Email Address*
example@example.com
Number of CME Credits Claimed*
maximum hours for this program is 9.25
Medical Organization Preparing for CME
e.g., American Medical Association (AMA), Accreditation for Pharmacy Education (ACPE)
Attestation Statement*

I hereby attest that I have completed the CME activity as described and the information provided is accurate.
Digital Signature*

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ACCME Accreditation Form for CME Credit