AAOS CME Joint Providership
INITIAL REQUEST
Date of Request:
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Organization Name
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Person
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First Name
Last Name
Telephone
*
-
Area Code
Phone Number
Email Address
*
Joint Providership is requested for the following CME activity:
Type of Activity
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Live Course/meeting
Activity Title
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Start Date
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End Date
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Location (City/State) -if applicable
Program Chair/ Editor
*
Planning Committee (please list)
*
Sources used to define the need for this activity:
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Summary of previous CME evaluation data
Request from committee/board
New research results
Healthcare data
Reports of studies
Thank you!
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