2022 APGO Virtual FDS CME Attendance Verification Form

Instructions:
1. Enter ALL information requested in the fields below.
2. Indicate the appropriate sessions attended and enter 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:
Total CME Credit for Sunday (01/09/2022)*
(Maximum 4 hours)
Total CME Credit for Monday (01/10/2022)*
(Maximum 4 hours)
Total CME Credit for Friday (01/21/2022)*
(Maximum 3 hours)
Total CME Credit for Friday (01/28/2022)*
(Maximum 3 hours)
Total CME Credit*
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: