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REGISTRATION FOR CME CREDIT

National Physicians Alliance - NATIONAL GRAND ROUNDS
The AMSA Scorecard: The State of Medical School Conflict-of-Interest Policies and Cultivating a New Era of Effective Change

This webcast was recorded for enduring material use at Georgetown University in Washington, DC on Tuesday, April 9, 2013.

Please provide the following information; incomplete applications will be returned and registration will
be delayed. All registration forms must be on file prior to distribution of CME or General Certificates.

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* 1. Name

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* 2. Degree

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* 3. Specialty

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* 4. Sub-specialty

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* 5. Title

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* 6. Affiliation

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* 7. Home Address

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* 8. Office Phone

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* 9. Home Phone

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* 10. Fax Number

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* 11. Email Address

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* 12. Physician License Number

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* 13. Number of CME credits claimed for this event

Please type your name below to serve as an electronic signature and confirm that you participated in the event and are eligible to receive the CME credits requested above

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* 14. Electronic Signature

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