REQUEST JOINT SPONSORSHIP INFORMATION

Thank you for your interest in CME Outfitters' joint sponsorship services. Please provide the following information or contact Richard Vanderpool and we will reply to your request as soon as possible. We look forward to working with you!

CONTACT INFORMATION
Name of Organization:
Address 1:
Address 2:
City:
State/Province:	Select state/province Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon Not in US or Canada
Zip/Postal Code:
Contact First Name:
Contact Last Name:
Contact Phone:	Fax:
Contact E-mail:
How did you hear about us?	Select one Direct mail E-mail Fax Word of mouth/colleague My organization's education department Pharmaceutical representative CME Outfitters website Another website/search engine Other
EVENT INFORMATION
Approximate date of your event:
Planned duration of your event:
Brief description of target audience and instructional format (symposium, teleconference, Internet, CD-ROM, etc.): (300 character maximum)
Does your event have a commercial supporter?	Yes No
What, if any, is the fee to participate in your event?
How many participants do you expect?
How many faculty members?
Type(s) of CE credit to be offered:
Are you interested in services in addition to joint sponsorship, such as our educational services or marketing and production services? Please tell us how we can help. (300 character maximum)