Agreed by Authorized Representatives. Commercial Interest Accredited Provider Signature and Date Signature and Date Print Name Print Name Title Title Educational Collaborator (if applicable) Signature and Date Print Name Title
Agreed by Authorized Representatives. Ineligible Company (Commercial Supporter/Exhibitor) Accredited Provider Signature Signature Print Name Print Name Title Title Date Date Xxxxx Xxxxxxx Medicine Course Director Educational Partner (if applicable) Signature Signature Print Name Print Name Title Title
Agreed by Authorized Representatives. Commercial Supporter Miami Children’s Hospital Signature and Date Signature and Date Xxxx X Xxxxxxx, M.D., MPH Print Name Print Name Chairman CME Title Title Educational Partner (If applicable) Signature and Date Print Name
Agreed by Authorized Representatives. Commercial Interest Accredited Provider (Indiana University) Signature and Date Signature and Date Print Name Print Name Title Title Joint Provider (if applicable) Signature and Date Print Name Title a The ACCME defines a Commercial Interest as any proprietary entity producing health care goods or services, with the exemption of non-profit or government organizations and non-health care related companies. The ACCME does not consider providers of clinical service directly to patients to be commercial interest.
Agreed by Authorized Representatives. Commercial Supporter Nicklaus Children's Hospital Signature and Date Signature and Date Xxxx X Xxxxxxx, M.D., MPH Print Name Print Name Chairman CME Title Title Educational Partner (If applicable) Signature and Date Print Name
Agreed by Authorized Representatives. Commercial Interest Accredited Provider Signature and Date Signature and Date Print Name Print Name Title Title Educational Partner/Joint Sponsor (if applicable) Signature and Date Print Name Title 1 The Medical College of Wisconsin (MCW) defines a Commercial Interest as any proprietary entity producing, marketing, re-selling or distributing health care goods or services consumed by, or used on, patients. MCW does not consider providers of clinical service directly to patients to be commercial interests. Units of the federal, state or local government are not considered to be commercial interests for CME purposes.
Agreed by Authorized Representatives. Commercial Interest Representative Accredited Provider - The Board of Trustees of the University of Arkansas acting for and on behalf of the University of Arkansas for Medical Sciences (UAMS), Office of Continuing Education Signature ____________________________________ Signature ___________________________________ Print Name ___________________________________ Print Name Xxx X. Xxxxx, MEd_____________ Title ________________________________________ Title ___Director of Continuing Education__________ Date ________________________________________ Date _______________________________________ The Board of Trustees of the University of Arkansas acting for and on behalf of the University of Arkansas for Medical Sciences Educational Partner (If applicable) Signature _____________________________________ Signature ___________________________________ Print Name _Xxxxxx Xxxxxx, CPA, MHSA Print Name _________________________________ Title _Vice Chancellor for Finance and Chief Financial Officer Title Date _________________________________________ Date ________________________________________
Agreed by Authorized Representatives. Commercial Interest Accredited Provider - SBUSOM Signature and Date Signature and Date Print Name Print Name Title Title Educational Partner (If applicable) Signature and Date
Agreed by Authorized Representatives. Accredited Provider University of North Texas Health Science Center at Fort Worth Office of Professional and Continuing Education (PACE) Tax ID Number 00-0000000 Contact Title Phone Fax E-mail Signature Date Commercial Supporter Name Title Phone Fax E-mail Signature Date
