APPLICATION FOR EVENT ENDORSEMENT Applicant InformationOrganization Name: * Primary Contact Name: * Primary Contact Title: * Preferred Mailing Address: * City: Province: * Zip/Postal Code: Country: * Phone Fax * Email * Website: * Event InformationTitle of Event: * Event Date(s): * Event Location: * Brief description of Event: Is this a recurring event? *YesNo How often will it recur? Annually Biannually Other: * Type of Event: *Abstract submissions with peer-reviewInvited, peer-reviewed educational presentationsRegional educational meeting with invited speakersThematic symposium with invited speakersProduct-driven educational meetingOther please provide description: Target Audience: * Please list the countries where attendees will come from and the estimated number. (if estimate is based on previous attendance figures, please note dates, location and attendance figures for a maximum of three years): Does your organization intend to provide CME for this event? *YesNo Names and affiliations of International Faculty who will participate in organizing the Event: * Names of other entities being approached for sponsorship, endorsement or funding of the Event: * VerificationPlease enter any two digitsExample: 12This box is for spam protection - please leave it blank
