Name of Society/Institution *

Address *

City *

Postal code *

Country

Phone (incl. country code)

Fax (incl. country code)

Website

Last Name *

First Name *

If different from above:

Address

City

Postal code

Country

E-mail address *

Direct phone (incl. country code) *

Direct fax (incl. country code) *

Name *

Address

City *

Postal code

Country *

Website

Event Title *

Start-date *
(dd/mm/yyyy)

End-date *
(dd/mm/yyyy)

Main language of the event *
(Please note that EBAP only accredits events in which English is the main language)

Will simultaneous translation be available? *

Will simultaneous translation be available? * Yes No

If yes, in which language(s)?

Expected number of attendees *

Target audience

Educational aims and methods *

Number of CME credits *
(number of CMEs you are asking for this event)

Event Programme *
(please upload the event programme)

Speakers *
(please upload the list of speakers, incl. contact details)

Will conflict of interest be monitored? *

Will conflict of interest be monitored? * Yes No

If yes, please explain how

Disclosure form
(please upload a sample disclosure form)

Will the quality of the event be monitored? *

Will the quality of the event be monitored? * Yes No

If yes, please explain how

Evaluation form
(please enclose a sample of the evaluation form distributed to participants)

Is there a method for verifying attendance? *

Is there a method for verifying attendance? * Yes No

If yes, please explain how

Are there assessment procedures for the participants (tests, examinations) foreseen in the CME activity? *

Are there assessment procedures for the participants (tests, examinations) foreseen in the CME activity? * Yes No

If yes, please give a short description

Will there be a self-assessment procedure/test proposed to the participants at beginning of event? *

Will there be a self-assessment procedure/test proposed to the participants at beginning of event? * Yes No

Will there be a self-assessment procedure/test proposed to the participants at the end of the event? *

Will there be a self-assessment procedure/test proposed to the participants at the end of the event? * Yes No

Will you use any commercial support for the event? *

Will you use any commercial support for the event? * Yes No

If yes, please indicate:

The type of of this commercial support

If yes, please indicate the type of support

The origin of this commercial support
(please indicate the name of the company and type of service)

The origin of this commercial support

Will there be any advertising during your event? *

Will there be any advertising during your event? * Yes No

If yes, which kind of advertising?

If yes, which kind of advertising?

Name(s) of the advertising company(ies):
(please list the companies advertising)

Type of advertising:
(please shortly describe the type of advertising)

Are there any exhibitions or stands during the event? *

Are there any exhibitions or stands during the event? * Yes No

If yes, please indicate the number of exhibitors/stands

Number of exhibitors/stand:

Are there any satellite programmes/sessions (educational programme organised by commercial companies) organised during the CME event? *

Are there any satellite programmes/sessions (educational programme organised by commercial companies) organised during the CME event? * Yes No

If yes, how many satellite sessions will be organised ?

If yes, how many satellite sessions will be organised ?

Please list the companies organising the satellite sessions

Please list the companies organising the Satellite sessions

EACCME Declaration on Disclosure: please upload the completed document*

EACCME Declaration on Disclosure *

EACCME Director's Declaration: please upload the completed document*

EACCME Director's Declaration *

If you wish to receive a notification e-mail providing you with a copy of your Live Event Accreditation Form, please enter the e-mail address it should be sent to here below

Notification e-mail address