AACE-Satellite-Symposium-Request-Form by xiagong0815


									AACE Satellite Symposium Request Form
Requests are made by medical education/management companies that wish to hold industry supported satellite symposia
at the AACE Annual Meeting. One form should be submitted per activity and commercial entity that the activity is
being submitted to for support. Please remember that request form must be submitted before any grant requests
are sent to potential commercial supporters, including responses to RFPs- grant requests may only be initiated once
authorization is provided by AACE.

Requesting Organization:
(Management Company)

Contact Person:

Phone:                                                    Email:


Title of Proposed Activity:

 Live Only

 Live +Enduring- please indicate which type(s) of enduring activities are being proposed (check all that apply):
    On-line Activity   CD-ROM/Tape Program            Stand-Alone Publication
    Endocrine Practice Journal Supplement       Two Media with exact same content e.g. Online & Monograph)
    Other, please describe (will require AACE approval and advice on fees):

   Please indicate if live and enduring activities are to be submitted on-
    Same Grant Request         Separate Grant Requests

Commercial entity that this activity will be submitted to for support:
                        Is this in response to an RFP?  Yes- RFP #
                                                          No

                    Grant requests may not be submitted until AACE authorization is provided.
         Please see AACE Satellite Symposia Guidelines for additional information regarding this process.

I have read the AACE Satellite Symposia Guidelines and agree to comply with all AACE policies and procedures
including, but not limited to-
       AACE is the sole accredited provider and grant payee for satellite symposia- both the live activity and any
        enduring spin-off materials. Applications with alternate provider/payee information cannot be accepted.
       Activity budget(s) must include the appropriate allotments for AACE live and enduring fees, along with other
        required expenses (i.e. brochure mailing, speaker expenses, etc.)

Authorized Signature:

Printed Name:                                                                      Date:

                                     Please send completed and signed forms to:
                                                Attn: LouAnn Griebel
                                    Email: lgriebel@aace.com; Fax: 904.535.7878
                                 245 Riverside Ave, Suite 200; Jacksonville, FL 32224

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