Company Name*
Address
City State Zip Code
Type of Business
Does your company provide medical care? Yes No
If yes, are you a Medicare or Medicaid provider? Yes No Does CFMC review your practice? Yes No
If yes, are you a Medicare or Medicaid provider? Yes No
Does CFMC review your practice? Yes No
Contact Name*
Contact E-mail Address*
Contact Phone Number*
How did you learn about CFMC?
What activity do you have in mind?
What is the name of your event?
Continuing Medical Education (CME) – number of physicians expected?
Continuing Nursing Education (CNE) – number of nurses expected?
How long is your activity? Hours Days
Where will this activity be held? (City, State)
What is the date of your first activity?
Funding: Will you have any commercial support? Yes No
If we contract for your educational activity, who will sign the contract?