2021 APGO Virtual CDS 301 CME Form

Instructions:
1. Enter ALL information requested in the fields below.
2. Indicate the total number of credits.
3. Sign your name and date the CME form.
4. Click Submit.
Participant Information:
Name*
First Middle Last Suffix
Medical License Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email*
Credit Claim:
4/8/21 - 2021 APGO Clerkship Directors’ School 301
Total Possible Credits: 4.5
Total Claimed CME Credit for 2021 APGO Clerkship Directors’ School 301*
Digital Signature*

I certify that the above information is correct and documents only those credits that I actually spent in the activity.
Date*
MM slash DD slash YYYY
Duplicate certificates will incur a $25.00 fee each. You can send a copy of your Certificate of Attendance to the ACOG CME Department for tracking.

Participant Information: