DECLARATION: As the of the scientific planning committee (or equivalent), I accept responsibility for the accuracy of the information provided in response to the questions listed on this application, and to the best of my knowledge, I certify that the CMA’s guidelines, entitled, CMA Policy: , and have been met in preparing for this event. Chair of the planning committee: Head of the physician organization: (print name) (print name) Signature: Signature: Electronic signatures are acceptable. Electronic signatures are acceptable. Date: Date: Please advise the CSIM office promptly if you do not receive a Notice of Receipt of Submission within 72 hours of submission. It is the applicant's responsibility to ensure the completed application has been received. FEE STRUCTURE NOTE: Applications will not be reviewed until all documentation and deposit are included. The review commences on the date the full and complete application package and deposit is received. The application fee is even in the event the application is declined. If the application is approved, this fee will be applied to the full accreditation fee. ACCREDITATION PROCESS NON-REFUNDABLE ORGANIZATION FEE APPLICATION FEE (Section 1 and Section 3) Physician organization Section 1 Approval $750 $500 NO funding for the event Physician organization $1,250 $1,000 Section 1 Approval With funding for the event Section 3 Approval Physician organization $1,250 $1,000 See page 13 for the forms. Educational co-development $12,000 where CSIM would be Plus $375 for each recurring event. represented on the planning NONphysician organization $2,000 committee from the onset of $1,500 grant administration fee per planning. each funding agreement. See page 13 for information.
DECLARATION: As the of the scientific planning committee (or equivalent), I accept responsibility for the accuracy of the information provided in response to the questions listed on this application, and to the best of my knowledge, I certify that the CMA’s guidelines, entitled, CMA Policy: , and have been met in preparing for this event. Chair of the planning committee: (print name) Signature: Electronic signatures are acceptable. Date: Head of the physician organization: (print name) Signature: Electronic signatures are acceptable. Date: Please advise the CSIM office promptly if you do not receive a Notice of Receipt of Submission within 72 hours of submission. It is the applicant's responsibility to ensure the completed application has been received. FEE STRUCTURE NOTE: Applications will not be reviewed until all documentation and deposit are included. The review commences on the date the full and complete application package and deposit is received. The application fee is even in the event the application is declined. If the application is approved, this fee will be applied to the full accreditation fee. ORGANIZATION ACCREDITATION PROCESS (Section 1 and Section 3) FEE NON-REFUNDABLE APPLICATION FEE Physician organization NO funding for the event Section 1 Approval $750 $500 Physician organization With funding for the event Section 1 Approval $1,250 $1,000 Physician organization Section 3 Approval See page 13 for the forms. $1,250 $1,000 NONphysician organization Educational co-development where CSIM would be represented on the planning committee from the onset of planning. See page 13 for information. $12,000 Plus $375 for each recurring event. $1,500 grant administration fee per each funding agreement. $2,000
CSIM_MOC_Application_Form.docx