Request Certification CME Form

CME ACCREDITATION REQUEST FORM
NAME OF CONTACT:
NAME OF CONTACT:
First
Middle
Last
(please indicate if you are requesting a meeting or session accreditation only)
(please indicate if you are requesting course accreditation only)
ACCREDITATION REQUEST FOR:

Maximum file size: 67.11MB

(if file cannot be uploaded, please email to familydoctorsregional@gmail.com

Maximum file size: 67.11MB

(if file cannot be uploaded, please email to familydoctorsregional@gmail.com)

Maximum file size: 67.11MB

(if file cannot be uploaded, please email to familydoctorsregional@gmail.com)
DESCRIPTION OF EDUCATIONAL METHODOLOGY TO BE USED:
METHOD OF PROGRAMM EVALUATION:
REQUESTING ACCREDITION THROUGH (Accrediting Body)
WEBINARS/MEETINGS ONLY – CME/WEBINARS/MEETING ACCREDITATION – I understand that there is an administrative cost for processing this application. Application for Chapters (in good standing) is US$150.00 per day: Affiliates of CCFP/Other Chapter- US$200.00 per day. Application for Non-Affiliates is US$300.00 per day. There is an additional cost for the Medical Council of Jamaica (if accreditation is required for Jamaican Physicians of J$5,000.
ONLINE/ON DEMAND COURSE CME/ACCREDITATION -I understand that there is an administrative cost for processing this application. Application for Chapters in good standing is US$300.00: Affiliates/Other Chapters is US$500.00. Application for Non-affiliates is US$800.00.
PLEASE NOTE: PAYMENT INFORMATION (Cheque made payable to the Caribbean College of Family Physicians or Direct Deposit to A/C#903674078, Bank of Nova Scotia, Liguanea Branch, Account type: USD Savings Account; or J$ A/C#0650267 Cheguing or Current Account or you can contact us for other options to pay. An estimate will be provided upon receipt of your application.
The Applicant is responsible for distribution of CME Certificates to attendees
A list of the attendee is to be provided to the CCFP at the end of the event
MEETING/CME ACCREDITATION ONLY: The applicant is responsible for designing its own promotional flyer, email CME Certificates to attendees and promoting event (if you require the CCFP to design flyer and promote event and email certificates to attendees please indicate), as these attract additional costs
ONLINE/ON DEMAND CME ACCREDITATION ONLY: The applicant is responsible for designing and promoting it online/on demand course. Applicant are to ensure that the signed CME Certificates for the attendees can be downloaded by each participant after completion of the course. (For promoting the online/on demand course an additional cost will be applicable.
Cost for additional Services are as follows. Please indicate that which is applicable
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