The PERT Consortium® PE Center of Excellence™ ProgramComprehensive Care and Regional Care Accreditations Survey

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:

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:

The PERT Consortium® PE Center of Excellence™ Program
Comprehensive Care and Regional Care Accreditations