Member Accreditation Form Meeting Accreditation Request Form Member Accreditation Form Please enable JavaScript in your browser to complete this form.CARIBBEAN COLLEGE OF FAMILY PHYSICIANS MEMBER ACCREDITATION APPLICATION FORMThis form is for application for Accreditation to the Caribbean College of Family Physicians. You will be required to deliver copies of your CME Certificates to the CCFP Secretariat for final verification.I confirm that I have completed 50 hours of CME activities each year or a total of 150 hours for the Triennium (3 years) *YesName *FirstLastConfirmation of Full Name *FirstLastEmail *Telephone Number *Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountrySpecialty *Country/Island *Years in practice *Number of years accreditation being applied for 1 year2 year3 yearAllPlease upload your CME Log Sheet here, or you can send to the CCFP Secretariat by email, then deliver to the CCFP copies of your CME Certificates to the CCFP Secretariat Click or drag a file to this area to upload. I confirm that the information and records I have provided are correct and accurate to the best of my knowledge (E&OE)Option 1Submit Meeting Accreditation Request Form Please enable JavaScript in your browser to complete this form. CARIBBEAN COLLEGE OF FAMILY PHYSICIANS CME ACCREDITATION REQUEST FORM (APPENDIX 12) 19a Windsor Avenue, Kingston 5, Jamaica, Tel: 876-517-6636 or 876-946-0954; Website: www.caribgp.org Member of the World Organization of Family Medicine National Colleges and Associations (WONCA) Please note that a separate application is required for each day and application must be submitted at least one (1) month prior to the event. (APPROVED BY THE CARIBBEAN COLLEGE OF FAMILY PHYSICIANS – CCFP) For a downloadable PDF version of this form, please click here. APPLICANT/ORGANIZATION *ADDRESS *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryEMAIL ADDRESS: *CONTACT TELEPHONE # *NAME OF CONTACT: *FirstMiddleLastLOCATION OF CME ACTIVITY: *DATE OF ACTIVITY: *DATE OF ACTIVITY: DATE OF ACTIVITY: DATE OF ACTIVITY: HOURS OF ACTIVITY: *NUMBER OF DAYS REQUESTING ACCREDITATION *MEETING ACCREDITATION (please indicate if you are requesting a meeting accreditation)DURATION OF COURSE (if course, please indicate duration of course in days or months)ACCREDITATION REQUEST FOR: *REGIONAL ONLYJAMAICA ONLYREGIONAL INCLUDING JAMAICACO-ORGANIZER TITLE OF PROGRAMME/ACTIVITY: *PROGRAMME OUTLINE/COURSE OUTLINE Click or drag a file to this area to upload. (if file cannot be uploaded, please email to familydoctorsregional@gmail.comCONFERENCES/SEMINARS/WEBINARS/MEETINGS: PROGRAM AGENDA (MANDATORY) Click or drag a file to this area to upload. (if file cannot be uploaded, please email to familydoctorsregional@gmail.comPLEASE UPLOAD CVS/BIOS FOR PRESENTERS Click or drag a file to this area to upload. (if file cannot be uploaded, please email to familydoctorsregional@gmail.comPROGRAMME GOALS *PROGRAMME OBJECTIVES *DESCRIPTION OF EDUCATIONAL METHODOLOGY TO BE USED (use the other option to list all the educational methodology to be used): *POWER POINT LECTURECLINICAL CASE STUDIESWORKSHOPPRE TESTOther:METHOD OF PROGRAMM EVALUATION:(use the other option to list all the options) *POST TESTQUESTIONS AND ANSWER SESSIONBREAK OUT SESSIONSPOLL QUESTIONSOther:CREDIT HOURS REQUESTING (PER DAY) *please indicateREQUESTING ACCREDITION THROUGH (Accrediting Body)CCFPJ CCFPR AGPJ AAFP (additional cost as requested by AAFP)Other:JAMAICA ONLY ACCREDITATION: Non-Affiliate / Pharmaceutical – US$489.00 per dayAffiliate Medical / Academic – US$389.00 per dayREGIONAL ACCREDITATION:Non-Affiliate / Pharmaceutical – US$489.00 per dayAffiliate Medical / Academic – US$389.00 per dayCCFP Chapters in Compliant with CCFP (Financially) – US$150.00 CCFP Chapters non-compliant with CCFP(not up to date Financially) – US$300.00ONLINE/ON DEMAND COURSESNon-Affiliate / Pharmaceutical – US$800.00 (if applied for as a standalone course)Affiliate Medical / Academic – US$500.00 (if applied as a standalone course)A list of the attendee is to be provided to the CCFP at the end of the event *NotedMEETING/CME ACCREDITATION: The applicant is responsible for designing its own promotional flyers and promoting event (if you require the CCFP to design flyer and promote event, these attract additional costsI need 2 email blast for promoting eventI need CCFP to design FlyerCost for additional Services are as follows. Please indicate that which is applicable FULL SERVICE PLUS IT Service – Contact SecretariatFULL SERVICE PLUS IT SERVICE – Contact SecretariatZOOM – US$200-$340Email Blast – US$80 per blastFlyer Designing – US$100Submit