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If you are a Medical Education Provider who wishes to participate in this breakthrough offering, please complete the form below: * Indicates Required Field / Question Contact Name:* Contact Email:* Organization Name:* Organization Type:* Select Type  1. Allied Healthcare Professional School  2. Health System  3. Healthcare Education Association  4. Hospital  5. Insurance Company  6. Medical Education Communication Company  7. Medical Education Communication Company Alliance (MECCA) Member  8. Medical School  9. Medical Specialty Society 10. Nursing School 11. Other 12. Other National Healthcare Association 13. Other State Healthcare Association 14. Pharmaceutical Alliance for CME Member (PACME) 15. Pharmaceutical Company 16. Pharmacy School 17. Physician Provider Group 18. State Medical Society 19. Veterans Affair Organization 20. Voluntary Health Organization Address:* State:* Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Phone:* City:* Zip:* Fax:* Does your Organization provide accreditation for activities? Yes No If Yes, check the accreditations that apply: ACCME ACPE ANCC Other If Other, list here Are you interested in expanding access to your online CME/CE activities? Yes No Does your Organization currently offer CME/CE Online? Yes No If Yes: Do you host and/or deliver your online CME/CE using your own online learning management system? Yes No  If No: Who currently hosts your online CME/CE? What type of CME/CE activities would you like to repurpose/offer through CE Medicus? Journals Monograph-Special Reports Slide sets (Only) Audio (Only) (i.e., from Tape) Video (Only) (i.e., from Tape) Teleconferences (Audio w/wo Slides) Live Symposia (Audio and/or Video w/wo Slides) Multimedia CD-ROM/DVD Other If Other, list here Comments or Questions: