ACPE Interest Form Step 1 of 3 - About Provider 33% About ProviderPlease provide information about the group that is organizing this education program.Name of Organization*Contact Name* First Last Contact Phone*Contact Email* About Education ProgramThe information provided in this section will be used to determine whether or not this course qualifies for continuing education (CE) credit. Please be as accurate as possible.Title of Education Program*Used to submit for CE creditDescription of Education Program*Education Program Learning Objectives*Please list at least 3 learning objectives for the education program. This information will be used to determine whether or not the course qualifies for CE.Target Audience*PharmacistTechnicianFull Name of Speaker*Please include full name (first, last) and any credentials (ie. PharmD, Esq)Speaker BioPlease include a bio/resume/CV of the speaker.Speaker bio/resume/CV uploads Drop files here or Date of Education Program* Date Format: MM slash DD slash YYYY Time Education Program is offeredExample: 5pm - 7pmLength of education program (number of hours)*1 hour1.5 hours2 hours2.5 hours3 hours3.5 hoursOver 3.5 hours (please contact CPhA)Location where program will be held (City, State)*Is there a registration fee for this program?*YesNoHow much is the registration fee?Approximately how many people do you expect to attend the event?Is this program sponsored?*YesNoName of Program Sponsor Acceptance of TermsI understand that this form has to be completed at least 21 days prior to the date the education course will occur.* I accept this term I understand that I may not promote the program as qualifying for CE until I receive written approval from CPhA.* I accept this term I understand that all my marketing collateral including brochures, flyers, and emails must include the CPhA logo and the approved UAN number. I also understand I will need to submit a copy of the marketing flyer to CPhA for approval.* I accept this term I understand that there shall be no commercial discussion or presentation inside the room the CE is taking place.* I accept this term I understand that it is my responsibility to track registration and submit an attendance list to CPhA using the template provided.* I accept this term I understand that it is my responsibility to supply the attendees with instructions (provided by CPhA) on how to go online to complete and evaluation and claim their CE credit.* I accept this term I understand that it is my responsibility to include in the presenter PowerPoint slide deck the Attendance Claim Code needed to claim credit (provided by CPhA).* I accept this term This iframe contains the logic required to handle Ajax powered Gravity Forms.