Office o
of C
Continuing Medical Education Request for eeds™ subscription and swipe card Return this form with the required documentation to: 4610 X Street, Suite 2301, Sacramento, CA 95817 or fax to (916) 734‐3580
The eeds™ system is a CME accreditation management system used to track attendance for Regularly Scheduled Series activities. The cost of an individual subscription is $15.00 annually and an additional $2.00 for the swipe card. Replacement cards cost $5.00 Complete the application and fax to Juliane Crowley, CME RSS Administrator at (916) 734‐7202, or mail to the address above. First Name: ____________________________________ Last Name: ________________________________________ Degree(s)/Certification(s): _____________________________ Date of Birth (mm/dd/yyyy): ____________________ E‐mail address: ___________________________________________ Phone number: ___________________________ Specialty: ____________________________________ Practice Name: _______________________________________ Mailing Address: ____________________________________________________________________________________ Are you a Fellow: If yes, please write down the beginning and end dates of your fellowship._____________________ Are you a Resident: __Yes __ No, If so what year: __1__ 2__ 3__ 4 expected graduation date: _________________ ______ I am requesting a subscription and swipe card for $17.00 ______ I am requesting a new/renewal subscription for $15.00 ______ I am requesting a replacement swipe card for $5.00 Please check your payment method: ___ Check payable to UC Regents ___AMEX, __Discover, __MasterCard, ___Visa Card number: Fill in form and Fax to (916) 734‐3580, then call in Credit Card # to Juliane Crowley at (916) 734‐7202. Expiration Date: ___________ CVC#___________ ____________________________________________ __________________________________________ Name on card Signature Department Re‐charge __________________________ _________________________________ ___________________________ Dept. Re‐charge 7 digit # Authorized Signature and Phone # Department Name S:\CHT\Cme\ACTIVITIES\RSS\Eeds\cme_eeds_swipecard_order_form.doc