Request Certification CME Form

ACCREDITATION REQUEST FOR: *

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 *

Administrative Cost for Services are as follows. Please indicate that which is applicable *

MCJ Fees: Please indicate that which is applicable *

Cost for additional Services are as follows. Please indicate that which is applicable *