Organization/Requester Information Organization/Requestor Name: * Primary Contact Name: * Primary Contact Title: * Email: * Organization Website: (If applicable) Please provide a brief description of the organization's mission: (If applicable) Program Information Title of the Activity: * Activity Format: * Conference/Meeting Online Interactive Program Online Webinar(s) Other... Activity Format: Other... Location: * Date(s): * Name of Activity Directors/Chairs: * Have we endorsed your activity before? If so, when and where? * Anticipated Number of Attendees: * Target Audience: * Is the activity’s location International or National (USA)? * International National Will commercial/industry support or sponsorship be provided for this activity? * Yes No If yes, please list all commercial sponsorships below, the actual or requested financial amount of support and how do you plan to eliminate the possibility of commercial bias in the program. * Please upload your drafted program/agenda: * Please include the following: - A brief description of the program - Educational objectives of the program - A list of faculty/authors involved in the program - Will continuing education credit(s) be offered? If so which? CME (Physician), CNE (Nursing), CPE (Pharmacy) - Any additional partnering organizations - Disclose any commercial/industry support or sponsorship for this activityFiles must be less than 2 MB.Allowed file types: jpg jpeg png txt rtf html pdf doc docx ppt pptx xls xlsx. How does your program support SHEA's Mission or Vision? * Check any additional requests for assistance by SHEA, outside the scope of Endorsement: * Co-Organization - Request for SHEA expert faculty participation Financial/Sponsorship Support - Request for partial financial support of the program Discounted Membership (International Requests Only) - Request for participants to receive a discount on SHEA Membership for participating in the program Number of Experts Requested: Will financial support be provided for speakers? Yes, financial support will be provided No, it is the responsibility of SHEA Monetary Request (in USD): $ Please outline what the requested funds will be utilized for: Have you requested any additional funding from other sponsoring organizations? * Yes No Leave this field blank
