Activity Information Activity Title: Activity Type: Application Date : Activity Dates: (dd/mm/yyyy) (dd/mm/yyyy) If offered live, how Application Review Date: 1 2 3 4+ many times will this (dd/mm/yyyy) event be held? 2nd Royal College Royal College Reviewer Reviewer If applicable How many hours are required to complete the program? Applicant Information Name of physician organization requesting accreditation: Name of Primary Contact for physician Email: organization applying for accreditation: Phone number: Address: Intended target audience of the activity:
Activity Information Activity Title: Activity Type: Application Date : (dd/mm/yyyy) Activity Dates: (dd/mm/yyyy) Application Review Date: (dd/mm/yyyy) If offered live, how many times will this event be held? 1 2 3 4+ Royal College Reviewer 2nd Royal College Reviewer If applicable How many hours are required to complete the program? Applicant Information Name of physician organization requesting accreditation: Name of Primary Contact for physician organization applying for accreditation: Email: Phone number: Address: Intended target audience of the activity:
provider-template-reviewer-ns-sap-activities-e.docx