Office of CME & PD
Accreditation Application Fee Payment Form
APPLICANT INFORMATION
First and Last name
Email
*Address:
Province/State:
Phone:
City
Postal Code/ZIP:
* Receipt will be mailed to the address provided here.
PROGRAM INFORMATION
Name of Program
Date(s) of Event:
PAYMENT INFORMATION (please check the applicable amount)
University of Calgary Application
Non-University of Calgary Application
CFPC Mainpro-M1 Application (Credits for Family Physicians)
Not Applicable
No Commercial Support
$250.00
Not Applicable
Commercial Support
$350.00
RCPSC MOC Section 1 Application (Credits for Specialists)
No Commercial Support
$300.00
$450.00
Commercial Support
$550.00
$700.00
CFPC Mainpro-M1 AND RCPSC MOC Section 1 Application (Credits for Family Physicians AND Specialists)
Not Applicable
No Commercial Support
$450.00
Not Applicable
Commercial Support
$800.00
RCPSC MOC Section 3 Application (Credits for Specialists)
No Commercial Support
$500.00
$650.00
Commercial Support
$700.00
$850.00
LATE APPLICATION - Applications received within 10 business days of the date of the event will NOT be accepted
$200.00 Late Fee for applications received within 2-6 weeks of the date of the event
METHOD OF PAYMENT (please check one)
Cheque - (Please make cheque payable to The University of Calgary)
University of Calgary IBD
Project:
Fund
Dept. ID
Account
Program
Operating:
AMEX
Card Number
Fund
Visa
Dept. ID
Project
Activity
Account
MasterCard
Expiry (MM/YY)
Signature
All completed forms may be faxed, emailed, or mailed to the Office of CME & PD
Mailing Address:
Fax: (403) 210-9247
Office of CME & PD
E-mail: cme@ucalgary.ca
TRW Building, 3280 Hospital Drive NW
Calgary AB T2M 4Z6
Effective October 26, 2015