Participant registration fee Departmental / faculty funding From a not-for profit company Name of not for profit supporter Amount or in kind contribution anticipated or received: From a for profit company Name of for profit supporter Amount or in kind contribution anticipated or received: Describe how will be used; including who is responsible for paying speaker honoraria and travel: Is accreditation/certification for this program sought with any other organization or group? Yes, Name of Organization: ____________________ No Attachments PowerPoint slides, handouts and/or materials for the program Disclosure slides and objectives slides used in the needs assessment /summary of needs assessment findings Program Agenda/ Brochure/Schedule with timing and interactivity labeled Speaker communication template (what instructions are given to speakers) Conflict of Interest forms for the planning committee and speakers Summary of previous event evaluations Copy of program/presenter evaluation form Budget (including revenue and expenses) I __________________ (planning committee chair) confirm that all information in this application is correct and complete. __________________________________ ____________ Signature Date
Participant registration fee Departmental / faculty funding From a not-for profit company Name of not for profit supporter Amount or in kind contribution anticipated or received: From a for profit company Name of for profit supporter Amount or in kind contribution anticipated or received: Describe how will be used; including who is responsible for paying speaker honoraria and travel: Is accreditation/certification for this program sought with any other organization or group? Yes, Name of Organization: ____________________ No Attachments PowerPoint slides, handouts and/or materials for the program Disclosure slides and objectives slides used in the needs assessment /summary of needs assessment findings Program Agenda/ Brochure/Schedule with timing and interactivity labeled Speaker communication template (what instructions are given to speakers) Conflict of Interest forms for the planning committee and speakers Summary of previous event evaluations Copy of program/presenter evaluation form Budget (including revenue and expenses) I __________________ (planning committee chair) confirm that all information in this application is correct and complete. __________________________________ ____________ Signature Date
1_CertificationAccreditationApplication_CFPC%20Updated.docx