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 CCFP Chapters (in good standing) is US$150.00 per day: Non-Affiliates of AGPJ/CCFP- US$200.00 per day; Pharmaceutical Companies - US$300.00 per day. Application for Regional Accreditation is US$300/per day across the board. There is an additional cost for the Medical Council of Jamaica (if accreditation is required for Jamaican Physicians of J$7,500/per day or (US$50/day). Please note that affiliates/other associates refers to Medical Doctors or medical groups.
ONLINE/ON DEMAND COURSE CME/ACCREDITATION -I understand that there is an administrative cost for processing this application. Application processing fee for AGPJ members is US$300.00: Other medical groups is US$500.00. Application for Non-affiliates, Pharmaceutical Companies is US$800.00. Please note that affiliates/other associates/medical groups refers to Medical Doctors or medical groups.
PLEASE NOTE: PAYMENT INFORMATION (Cheque made payable to the Association of General Practitioners of Jamaica or Direct Deposit to A/C#371000365, NCB, Matildas Corner Branch, Account type: J$ 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.
The Applicant is responsible for distribution of CME Certificates to attendees
A list of the attendee is to be provided to the AGPJ Secretariat 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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