Form

APPLICATION (PHARMACEUTICAL COMPANY):
ADDRESS FIELD

Address Line 1 *

Address Line 2

City *

State *
FAX #
NAME OF MEDICAL REPRESENTATIVE:
CONTACT TELEPHONE NO
E-MAIL ADDRESS
DATE OF ACTIVITY
LOCATION OF CME ACTIVITY
REGIONAL MEETING (CARIBBEAN ETC.) *
LOCAL MEETING (JAMAICA ONLY) *
DURATION OF ACTIVITY (HOURS)
TITLE OF PROGRAMMME/ACTIVITY
PROGRAMME CONTENTS
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PROGRAMME GOALS
PROGRAM OBJECTIVES
DESCRIPTION OF EDUCATIONAL METHODOLOGY TO BE USED
METHOD OF PROGRAMME EVALUATION
CREDIT HOURS REQUESTED
NUMBER OF SPEAKERS
NUMBER OF OVERSEAS SPEAKERS
NUMBER OF LOCAL SPEAKERS
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