Name of Applicant:*

Email Address:*

EABIP Member Society:

Program Title:*

Program Director:

Program Date:*

Program Location:*

Program Type (select all that apply):*
Educational seminar (postgraduate may include physicians in practice and trainees)Educational seminar (for trainees only)Hands-on workshopConference (didactic lectures)

Learning Objectives:*

Major funding sources:*

Other potential sponsors:*

Are Continued Medical Education credits (or equivalent) being offered?*
YesNo

Upload the scientific program (preliminary or finalized) (max 10MB):*

Upload image of your brochure, flyer or other marketing materials (max 10MB):

Website address:

Additional information or comments:

AGREEMENT

As a condition of EABIP endorsement of this program, I hereby agree that:
(Must check all boxes) *

The EABIP logo will be inserted into marketing and program materialsThe EABIP officially endorses this program but does not provide financial support or sponsorship of any program-related eventsI shall encourage the event attendees to join the EABIPIf the event date is less than 30 days from the application date, I understand and agree that the CME review committee may not finalize this application in time for the event.

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