Rev. 5-01-10
S A M P L E
P H Y S I C I A N
S I G N - I N
Jointly Sponsored Activity
P H Y S I C I A N
C M E
C R E D I T
NAME OF PROGRAM
Date
Location
This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for
Continuing Medical Education through the joint-sponsorship of the Kentucky Medical and ______________________________.
The following speakers disclose: _______________________________________________.
The following meeting planners disclose __________________________________________.
The following speakers disclose they have nothing to disclose. __________________________________________________
The following meeting planners disclose they have nothing to disclose. ___________________________________________
The Kentucky Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing
medical education for physicians.
The Kentucky Medical Association designates this continuing medical education activity for ___ AMA PRA Category 1 Credit(s)™.
Physicians should only claim credit commensurate with the extent of their participation in the activity.
NOTE: Legibility is necessary in order for you to receive your CME certificates.
NAME and EMAIL
(PLEASE PRINT)
CERTIFICATE
VIA EMAIL
SPECIALTY
LICENSE
NUMBER
COMPLETE ADDRESS
PHYSICIAN CME CREDIT
Rev. 5-01-10
PHYSICIAN CME CREDIT