Request Certification CME Form CME ACCREDITATION REQUEST FORM APPLICANT/ORGANIZATION * ADDRESS * Address Line 1 * Address Line 2 * City State / Province / Region Postal Code * Country * AustraliaCanadaJamaicaUKUSA Country Email * CONTACT TELEPHONE # * NAME OF CONTACT: * NAME OF CONTACT: First First Middle Middle Last Last LOCATION OF CME ACTIVITY: * DATE OF ACTIVITY: * DATE OF ACTIVITY: * DATE OF ACTIVITY: * DATE OF ACTIVITY: * HOURS OF ACTIVITY: * NUMBER OF DAYS REQUESTING ACCREDITATION * MEETING/SESSION ACCREDITATION * (please indicate if you are requesting a meeting or session accreditation only) COURSE ACCREDITATION (please indicate if you are requesting course accreditation only) ACCREDITATION REQUEST FOR: * REGIONAL JAMAICA ONLY REGIONAL INCLUDING OWN JURISDICTION MY LOCATION ONLY CO-ORGANIZER * TITLE OF PROGRAMME/ACTIVITY: * PROGRAMME OUTLINE/COURSE OUTLINE Drop a file here or click to upload Choose File Maximum file size: 67.11MB (if file cannot be uploaded, please email to familydoctorsregional@gmail.com COURSE/WEBINARS/MEETING PROGRAM AGENDA (MANDATORY) Drop a file here or click to upload Choose File Maximum file size: 67.11MB (if file cannot be uploaded, please email to familydoctorsregional@gmail.com) PLEASE UPLOAD CVS/BIOS FOR PRESENTERS Drop a file here or click to upload Choose File Maximum file size: 67.11MB (if file cannot be uploaded, please email to familydoctorsregional@gmail.com) PROGRAMME GOALS * PROGRAMME OBJECTIVES * DESCRIPTION OF EDUCATIONAL METHODOLOGY TO BE USED: * POWER POINT LECTURE CLINICAL CASE STUDIES WORKSHOP PRE TEST Other METHOD OF PROGRAMM EVALUATION: * POST TEST QUESTIONS AND ANSWER SESSION BREAK OUT SESSIONS POLL QUESTIONS Other CREDIT HOURS REQUESTING (PER DAY OR PER SESSION) * REQUESTING ACCREDITION THROUGH (Accrediting Body) * MCJ AGPJ MCJ & AGPJ AAFP (additional cost as requested by AAFP) Other 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. * I am a Pharmaceutical company I am an Affiliate/other associate of AGPJ I do not need MCJ Accreditation I am a non-Affiliate of AGPJ (not an associate/not affilliated) Not applicable 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$800.00. * I am a pharmaceutical company (in good standing) I am an Affiliate/Other I am a non-affiliate or pharmaceutical company) Not applicable PLEASE NOTE: PAYMENT INFORMATION (Cheque made payable to the Association of General Practitioners of Jamaica or Direct Deposit to A/C#371000365, NCB, Matildas Corner Branch, Account type: J$ Chequing or Current Account or you can contact us for other options to pay. An estimate/invoice will be provided upon receipt of your application. * Yes The Applicant is responsible for distribution of CME Certificates to attendees * Yes A list of the attendee is to be provided to the AGPJ Secretariat at the end of the event * Noted 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 Yes No Maybe I need 2 email blast for promoting event I need AGPJ to design Flyer 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. Yes Not Applicable Maybe I need 2 email blast for promoting event Cost for additional Services are as follows. Please indicate that which is applicable * Full IT Service – US$1000 ZOOM – US$100-$340 Email Blast – US$80 per blast Bulk Email Certificates – US$195 Flyer Designing – US$100 Service not needed If you are human, leave this field blank. Submit
