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The PERT Consortium® PE Center of Excellence™ Program
Comprehensive Care and Regional Care Accreditations
Overview of Process Steps:
Please complete this form to officially initiate the PE CoE Application process. Once the form has been submitted, an invoice will be generated.
1.
Name of Institution:
2.
Nickname of Institution (if applicable):
3.
Name of Healthcare System (if applicable):
4.
Institution Address:
Street:
City:
State:
Zip Code:
5.
Outside of the United States:
State/Region/County/ Territory/Province:
Country:
6.
What type of PE CoE will your institution be applying for (criteria linked here)
Comprehensive Care PE Center of Excellence
Regional Care PE Center of Excellence
Uncertain
7.
Institution's PERT Team Leader Contact Information:
First Name:
Last Name:
Credentials/Title:
Specialty:
Email Address:
Phone Number:
8.
Institution's Finance Contact Information (for invoicing and payment purposes):
Name:
Title:
Email:
Phone Number:
9.
Form of payment for the nonrefundable application fee:
Check
ACH
10.
Who should the legal documents be sent to for review and signature?
Contact Name:
Contact Email:
Contact Number:
11.
If applicable, please fill out other institutional members that will be involved with the application process:
Contact 1 First Name:
Contact 1 Last Name:
Contact 1 Email:
Contact 2 First Name:
Contact 2 Last Name:
Contact 2 Email:
Contact 3 First Name:
Contact 3 Last Name:
Contact 3 Email:
