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)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/SESSION ACCREDITATION * (please indicate if you are requesting a meeting or session accreditation only)COURSE ACCREDITATION * (please indicate if you are requesting course accreditation only)DURATION OF COURSE * (please indicate duration of course in days or months)ACCREDITATION REQUEST FOR: *CCFP REGIONAL ONLYJAMAICA ONLYREGIONAL INCLUDING OWN JURISDICTIONREGIONAL INCLUDING JAMAICAMY LOCATION ONLYCO-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.comCOURSE/WEBINARS/MEETING 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 OR PER SESSION) *REQUESTING ACCREDITION THROUGH (Accrediting Body)CCFPJ & MCJ CCFPR ONLYAGPJ & MCJAGPJ, CCFPR & MCJMCJ & CCFPJ, CCFPRAAFP (additional cost as requested by AAFP)Other:WEBINARS/FACE-TO-FACE MEETINGS/WORKSHOPS ONLY – CME/WEBINARS/MEETING ACCREDITATION – I understand that there is an administrative cost for processing this application. Application for Chapters (in good standing) is US$150.00 per day: Affiliates of CCFP/Other Chapter- US$200.00 MCJ-NCCME/US$300.00 CCFP-NCCME per day. Application for Non-Affiliates is US$300.00 MCJ-NCCME/US$350 CCFP-NCCME per day. There is an additional cost for the Medical Council of Jamaica (if accreditation is required for Jamaican Physicians of J$7,500. *I am a Chapter of CCFP (in good standing)I am an Affiliate/other chapter of CCFPI do not need MCJ AccreditationI am a non-Affiliate of CCFP (not a chapter/not affilliated)Not applicableONLINE/ON DEMAND COURSE CME/ACCREDITATION -I understand that there is an administrative cost for processing this application. Application for Chapters in good standing is US$300.00: Affiliates/Other Chapters is US$500.00. Application for Non-affiliates is US$800.00. *I am a Chapter (in good standing) I am an Affiliate/Other ChapterI am a non-member of CCFP (not a chapter/not affilliated)Not applicableFACE-TO-FACE MEETINGS/ONLINE/HYBRID MEETING/ON DEMAND COURSE CME ACCREDITATION & CME: (REQUESTING CREDITS (CMES) FOR JAMAICA, REGIONAL AND OWN JURISDICTION- I understand that there is an administrative cost for processing this application. Application for Chapters in good standing is US$200: Affiliates/Other Chapters is US$400. Application for Non-affiliates is US$500.00. *I am a Chapter (in good standing) I am an Affiliate/Other ChapterI am a non-affiliate of CCFP (not a chapter/not affilliated)Not applicableFACE-TO-FACE/ONLINE/HYBRID/ON DEMAND/TRAINING COURSES- ACCREDITATION & CME: (REQUESTING CREDITS (CMES) FOR JAMAICA, REGIONAL AND OWN JURISDICTION- I understand that there is an administrative cost for processing this application. Application for Chapters in good standing is US$200: Affiliates/Other Chapters is US$400. Application for Non-affiliates is US$500.00. *I am a Chapter (in good standing) I am an Affiliate/Other ChapterI am a non-affiliate of CCFP (not a chapter/not affilliated)Not applicablePLEASE NOTE: PAYMENT INFORMATION (Cheque made payable to the Caribbean College of Family Physicians or Direct Deposit to A/C#903674078, Bank of Nova Scotia, Liguanea Branch, Account type: USD Savings Account; or J$ A/C#0650267 Cheguing or Current Account or you can contact us for other options to pay. An estimate will be provided upon receipt of your application. and your invoice will have other payment link to make payment directly to our account *YesThe Applicant is responsible for distribution of CME Certificates to attendees *YesNeed CCFP to distribute CertificatesA list of the attendee is to be provided to the CCFP at the end of the event *NotedMEETING/CME ACCREDITATION ONLY: The applicant is responsible for designing its own promotional flyer, email CME Certificates to attendees and promoting event (if you require the CCFP to design flyer and promote event and email certificates to attendees please indicate), as these attract additional costs *YesNoMaybeI need CME Certificates to be emailed onlyI need 2 email blast for promoting eventI need CCFP to design FlyerMEETING/CME ACCREDITATION ONLY: The applicant is responsible for designing its own promotional flyer, email CME Certificates to attendees and promoting event (if you require the CCFP to design flyer and promote event and email certificates to attendees please indicate), as these attract additional costs (copy) *YesNoMaybeI need CME Certificates to be emailed onlyI need 2 email blast for promoting eventI need CCFP to design FlyerONLINE/ON DEMAND CME ACCREDITATION ONLY: The applicant is responsible for designing and promoting it online/on demand course. Applicant are to ensure that the signed CME Certificates for the attendees can be downloaded by each participant after completion of the course. (For promoting the online/on demand course an additional cost will be applicable. *YesNot ApplicableMaybeI need 2 email blast for promoting eventONLINE/ON DEMAND CME ACCREDITATION ONLY: The applicant is responsible for designing and promoting it online/on demand course. Applicant are to ensure that the signed CME Certificates for the attendees can be downloaded by each participant after completion of the course. (For promoting the online/on demand course an additional cost will be applicable. (copy) *YesNot ApplicableMaybeI need 2 email blast for promoting eventONLINE/ON DEMAND CME ACCREDITATION ONLY: The applicant is responsible for designing and promoting it online/on demand course. Applicant are to ensure that the signed CME Certificates for the attendees can be downloaded by each participant after completion of the course. (For promoting the online/on demand course an additional cost will be applicable. (copy) (copy) *YesNot ApplicableMaybeI need 2 email blast for promoting eventCost for additional Services are as follows. Please indicate that which is applicable *Full IT Service – US$1000ZOOM – US$100-$340Email Blast – US$80 per blastBulk Email Certificates – US$195Flyer Designing – US$100Service not neededCost for additional Services are as follows. Please indicate that which is applicable (copy) *Full IT Service – US$1000ZOOM – US$100-$340Email Blast – US$80 per blastBulk Email Certificates – US$195Flyer Designing – US$100Service not neededSubmit