Group CME Application Form

Practicing Physician Name & Contact Information

First Name *

Last Name *

Phone Number *

Email *

Host Organization or Medical Corporation Name:

Name *

Phone Number *

Address Line 1 *

Address Line 2

City *

Province *

Postal Code *

Finance Contact Name

Finance Contact Phone Number *

Finance Contact Email *

Pre-Authorized Deduction Authorization Form Banking Information

Please include all numbers, including leading zeros.

Upload Banking Information here

Attaché a void cheque or direct deposit form (image or pdf)

Transit Number

(5 digits)

Financial Institution Number

(3 digits)

Account Number

Please enter your account number

If a government, regional health authority, college or academic institution was identified as the host organization, please describe their funding allocation to this initiative and the percentage contribution to the overall budge of the CME: *

Please check one *

GFT Physician Applicant

Community-based Physician Applicant

Rural or Northern Physician Applicant

Amount Requested *

Budget for CME: *

You can either enter the information directly or upload a document.

Please upload your budget here, if necessary.

Date of CME *

If multiple dates, please indicate here.

Location of CME *

Learning Objectives *

Please enter the learning objectives or upload a document.

Please upload the learning objectives here, if necessary.

Expected Impact of CME *

Please enter the expected impact details here or upload a document

Please upload the expected impact document here, if necessary

Accreditation Body *

Confirmation of accreditation is required before funds will be dispersed.

Expected Attendance of Eligible Practicing Physicians: *

Expected Attandance from Other Health Care Professionals:

Would you like Doctors Manitoba to promote this event to the broader membership *

Yes

Last updated

March 10, 2023

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Group CME Application Form

Pre-Authorized Deduction Authorization Form Banking Information