CE Program Request Form

Event Details

* Contact Name First and Last Name, Company/Institution

* Contact Email

* Contact phone number (xxx) xxx-xxxx

* Event Date MM/DD/YYYY

* Event Location Must be in Dane County

* I agree that over 50% of invitees are from within Dane County, WI. This is a requirement for approval.

* Expected Attendance

Program Details

* Presentation Title

* CE Credit Hours Requested (0.5 hours per 25 min)

* Learning Objectives for Presentation List at least 5 to 7 key points to be made in the presentation

Speaker Qualifications

* Name First and Last Name

* Degree(s) eg, DVM, PhD

* Credentials eg, DACVIM, DACVS

* Employment Affiliation eg, Pharma/Food Company Name, Clinic Name

Curriculum Vitae (PDF format) Please attach CV if the speaker is not a specialist from the Dane County, WI area. The speaker's publications, direct experience, or previous CE presentations related to topic should be included.

* Demonstration of Expertise in Area of CE Program List the speaker's publications, direct experience, or previous CE presentations related to topic

* Speaker Disclosures Listing of related entities from which the speaker receives compensation. NOTE: Disclosures must also be disclosed at the start of the presentation.

CE PROGRAM REQUEST SUBMISSION Checklist

Completed application should be electronically submitted via this form at least 6 weeks before scheduled event.
Applicant has read the DCVMA CE Approval Guidelines and attests that this program meets the requirements for approval
DCVMA must approve the CE request prior to the event in order for CE credits to be allocated.

Once your application is received, please allow 5 business days for processing and further instructions. If you do not receive communication from us after that time, please contact us at [email protected] to ensure that your CE credits can be granted.

Any questions can be emailed to [email protected] - please allow 5 business days for a response

* Applicant Signature

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