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* 1. Today's Date 

Date

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* 2. Your first name, last name and title

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* 3. Your email address 

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* 4. Your phone number 

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* 5. Organization name

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* 7. Organization Street Address

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* 8. Organization City and Zip Code

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* 9. Organization County

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* 10. Has your organization hosted a CEI training in the past?

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* 11. What type of program would you like to schedule?

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* 12. What training modality works best for your organization?

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* 13. For the webinar, who would you like on camera?

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* 14. Would you like the speaker to incorporate multiple choice polling questions into the presentation?

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* 15. How many people do you expect to attend this training program in total? (Minimum of 10 attendees)

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* 16. Who is the audience for the proposed training?

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* 17. We provide the following Continuing Education (CE) credit types: Continuing Medical Education (CME), Continuing Nursing Education (CNE), and Continuing Pharmacy Education (CPE). Would you be interested in offering CE to your attendees?

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* 18. Which specific course(s) would you like for your CEI training? (All trainings are one hour and 1 CE credit [CME, CNE, or CPE], unless stated otherwise)

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* 19. Due to the CEI CE accreditation process, we require at least 40 days notice from the official booking confirmation of the training(s). What date(s)/time(s) would you like to request?

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* 20. Are there any special requests you have pertaining to your selected training(s)?

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