2024 APGO 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 (MD, DO, etc.)*
Suffix
Medical License Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email*
Credit Claim:
2/28/24 - 2024 APGO Clerkship Directors’ School 301
Total Possible Credits: 4.25
Total Claimed CME Credit for 2024 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.

Participant Information: