Tom Test Form Page

Organization

Name

Tax ID

Legal Entity Name (if different)

Type of Organization

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Website

Contact

Email*

Is your organization involved in providing commercial or other company-directed activities or services for ineligible entities/commercial interests including, but not limited to, advertising/promotional services, publication planning, speaker bureau management, speaker training, and advisory board/ consultant meeting planning?

Yes
No

A parent organization is defined as one that owns and fiscally controls another organization. In that context, do you have a parent organization?

Yes
No

If yes, please identify your parent organization.

Name

Tax ID

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Website

Is your organization part of a larger family of companies that is affiliated with any other organization(s) (i.e. do you have any sister companies)?

Yes
No

Is any organization (sister company) with which you are affiliated involved in providing commercial or other company-directed activities or services for pharmaceutical companies, medical device manufacturers, nutraceutical or herbal supplement companies, etc., including but not limited to advertising/promotional services, publication planning, speaker bureau management, speaker training, and advisory board/consultant meeting planning?

Yes
No

The ACCME defines an ineligible entity/commercial interest as “those whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.” Do you believe that your organization or your parent organization is a commercial interest as defined by the ACCME?

Yes
No
N/A

Attestation

I hereby certify that the above information is correct and that the CME Outfitters will be immediately notified if any of the above information changes.

Signature

Date

Title

Tom Test Form Page

Organization

Attestation

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