Institute for Continuing Medical Education
New York NY 10003
Phone 212-614-8269 or 212-979-4444
e-mail firstname.lastname@example.org or email@example.com
CME CERTIFICATE REQUEST FORM
DATE OF EVENT
Dear Course Participant:
To receive your CME certificate, please complete this CME Certificate Request Form and the attached Activity
Evaluation Form. Your CME certificate will be mailed to you upon our receipt of these completed forms.
Please note that CME credits are awarded on the basis of the number of hours you attended the course, i.e. one
hour of credit is awarded for every hour you attended the program. Please indicate below the actual number of
hours you were in attendance. The maximum number of credits that may be claimed for this Continuing
Medical Education activity is .
Please provide all of the requested information below. This information assures that your certificate is filled out
correctly and is mailed to the proper address. It also enables us to contact you about future CME activities.
PLEASE PRINT legibly or we will be unable to process your request for a certificate.
First Last Degree
Street Suite/Apt #
City State Zip
Phone Fax E-mail
I certify that I attended hour(s) of the educational activity noted above.
To receive your CME Certificate, please mail or fax this form and the completed Activity Evaluation to:
Kimberly Corbin, Director, ICME
The New York Eye & Ear Infirmary
310 East 14th Street - ICME
New York, NY 10003
Phone: 212-979-4444 Fax: 212-353-5703
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