**PLEASE CLICK PRINT A COPY OF THIS APPLICATION FOR YOUR RECORDS BEFORE SUBMITTING**
REMINDER:
In addition to this application you need to submit the following documentation via e-mail to mpalumbo@health-quest.org unless otherwise noted:
1. Signed Joint Providership Agreement (online submission)
2. CVs for all Presenters/Faculty
3. Disclosures for Education Director, Planners, and Speakers
4. Agenda
5. Commercial Support Agreement(s) (if applicable)
*Invoice for the application fee must be paid within 30 days of the invoice date*
Submitted Post Activity:
1. Copy of flyer/brochure with appropriate accreditation statements
2. Attendance Record
3. Participants Evaluations
4. Faculty Evaluation
5. Educational Director Evaluation
6. Handout Material/Syllabus (if applicable)
7. Articles: Copyright obtained (if applicable)
8. Other Documentation for Outcomes Data (if applicable)
PLEASE NOTE CERTIFICATE TEMPLATES FOR PARTICIPANTS AND FACULTY WILL BE SENT TO YOU ONCE YOU HAVE RECEIVED APPROVAL.