REGISTER YOUR INSTITUTION

Thank you for your interest in receiving high quality medical education programming from CME Outfitters. Please tell us about your institution so that we can determine your existing reception capabilities. This information will also help us determine your eligibility for no-fee installation of receiving equipment, if necessary.

If you have any questions or comments prior to registering, please call 877.CME.PROS (877.263.7767) or e-mail: . Note: your browser MUST accept cookies from cmeoutfitters.com in order to log in or register.

CONTACT INFORMATION
Site Name:
Site Address 1:
Site 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 Newfoundland New Hampshire New Jersey New Mexico New York 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:
CME Department Contact:
Name:		E-mail:
Phone:		Fax:
Psychiatry Department Contact:
Name:		E-mail:
Phone:		Fax:
A/V Medical Media Contact:
Name:		E-mail:
Phone:		Fax:

SITE PROFILE
Ku-band C-band Other steerable equipment	GE Tip TV Other, please explain:
This site has no compatible equipment but we would like information on no-fee installation (subject to minimum requirements). Please list all physicians affiliated with your psychiatry department (for tracking utilization and to help us determine if your site meets minimum requirements for no-fee installation of equipment):

AUDIENCE PROFILE
How many total physicians do you expect to participate in CME Outfitters activities?
How many total clinicians do you expect to participate in CME Outfitters activities?
Please include any comments or questions here: