ACE Application v3 ACE Application v3 Primary Contact Details First Name * Last Name * Email * Phone * Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Name of the Event Sponsor * Sponsor Website Activity Details Type of Activity * Single Session Multisession Program Commercial Entities Type of Single Session Activity * Review Course Self-Study Session (Must provide quiz and answers) Directed Reading (Must provide copy of article) Live – Course/Lecture/Seminar Recorded/Enduring – Course/Lecture/Seminar Type of Multisession Activity * 1 Day 2-3 Days 4+ Days Type of Commercial Entities * 1-year approval 2-year approval Did you get the multi-day template? Please use this template for all multi-day submissions to ensure a complete application. Click here to download the Excel form template. Event/Activity Title * Website for the Event/Activity Is this a Renewal? * No Yes Category * A (RT Credits) A+ (RT, RPA & RRA Credits) Is your event within the next 28 days? * Yes No Start Date * End Date * Activity Length (minutes) * Total CE(s) Applied For * Total years Applied For * Participation Verification Method * Journal Issue and Number if Applicable Speaker Name * Speaker CV Drop a file here or click to upload Choose File Maximum file size: 30MB Please note files over 30mb should be compressed with Adobe Acrobat or other PDF compression utility. Abstract & Objectives/Publication or Article/Quiz Materials Drop a file here or click to upload Choose File Maximum file size: 30MB Please note files over 30mb should be compressed with Adobe Acrobat or other PDF compression utility. Proof of Authorized Use of Materials Drop a file here or click to upload Choose File Maximum file size: 30MB Please note files over 30mb should be compressed with Adobe Acrobat or other PDF compression utility. Upload the events agenda/schedule Drop a file here or click to upload Choose File Maximum file size: 30MB Please note files over 30mb should be compressed with Adobe Acrobat or other PDF compression utility. Additional Comments or Details ACE Policies Speaker Conflict of Interest Disclosure Policy Any presenter of a course that has been approved for AVIR CE shall disclose any financial interest, arrangement of affiliation with one or more organizations/companies that could be perceived as a real or apparent conflict of interest in the context of the subject of the presentation, including but not limited to: consulting; a family member employed by the organization; a fiduciary responsibility; membership on a governing board; recipient of a grant or research support; a major stockholder; receiving other financial or material support (e.g., honorarium and/or travel expense reimbursement), membership on a speaker’s bureau. This policy is not intended to prevent a speaker from making a presentation but merely to identify any potential conflict. Disclosure of Commercial Support Policy Any presenter or provider of a course that has been approved for AVIR CE shall prior to the activity disclose whether or not there is: Any vested or financial interest(s) or relationship(s) with the manufacture(s) of commercial product(s) or provider(s) of commercial services or Any uses of unlabeled products under investigational use. Disclosure does not prohibit the provision of courses or the awarding of CE credit; merely, there must be proper planning, proper disclosure, and the proper documentation kept on file. Once you continue to payment you will no longer be able to edit the form. I agree to the AVIR Policies * Yes No You cannot continue further without consenting to the AVIR Policies. Please choose “Yes” to proceed. If you have any questions, contact us. ACE Single Activity 0.25 – 5.0 Credits – 1 year ACE Single Activity Fee: $85.00 ACE Single Activity 5.25 – 10.0 Credits – 1 year ACE Single Activity Fee: $95.00 ACE Single Activity 10.25+ Credits – 1 year ACE Single Activity Fee: $105.00 ACE Single Activity 0.25 – 5.0 Credits – 2 years ACE Single Activity Fee: $145.00 ACE Single Activity 5.25 – 10.0 Credits – 2 years ACE Single Activity Fee: $165.00 ACE Single Activity 10.25+ Credits – 2 years ACE Single Activity Fee: $185.00 ACE Single Activity 0.25 – 5.0 Credits – 3 years ACE Single Activity Fee: $200.00 ACE Single Activity 5.25 – 10.0 Credits – 3 years ACE Single Activity Fee: $230.00 ACE Single Activity 10.25+ Credits – 3 years ACE Single Activity Fee: $265.00 ACE Multi-Session Activity – 1 Day ACE Multi-Session Activity: $150.00 ACE Multi-Session Activity – 2-3 Days ACE Multi-Session Activity: $310.00 ACE Multi-Session Activity – 4+ Days ACE Multi-Session Activity: $430.00 ACE Commercial Entities 1-year approval ACE Commercial Entities: $800.00 ACE Commercial Entities 2-year approval ACE Commercial Entities: $1,500.00 Discount Code Discount Factor Renewal Discount % 10% Renewal Discount Rush Application Fee $ Late Fee Applied Sub Total Total If you are human, leave this field blank. 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