Organizational Intent to Apply -- Joint Accreditation Process

Our organization meets the eligibility criteria set for providers wishing to engage in the Joint Accreditation process. Therefore, we are providing ACCME, ACPE, and ANCC with written confirmation of our intent to apply for joint accreditation.

Please provide the following information and submit this form with the Joint Accreditation Fee:

Organizational Information
Name of Organization: Date :
Accreditation (check all that apply) / Most recent accreditation cycle dates:
From / To
Accreditation Council for Continuing Medical Education (ACCME)
Accreditation Council for Continuing Pharmacy Education (ACPE)
American Nurses Credentialing Center (ANCC)
ACCME Recognized Accreditor:
ANCC Accredited Approver:
Percentage of CE activities designed by and for the health care team in the last 18 months:
Primary Contact for Organization:
Note: The name and information provided for the organization’s primary contact will be used as the contact information for communicating with the organization. Postal deliveries, shipments, telephone calls, email and fax transmissions will be directed to the individual identified as the Primary Contact using the contact information provided below.
Name:
Title:
Address:
Telephone number: / Fax number:
e-mail address:
Chief Executive Officer of Organization:
Name:
Title:
Address:
Telephone number: / Fax number:
e-mail address:
Date Self Study Report and Activity Files will be submitted:
For November decision, July 1 For July decision, March 1
I understand that:
·  If I do not receive joint accreditation, I may apply for accreditation individually through ACCME, ACPE and/or ANCC provided that I submit my application at the next scheduled cycle submission date.
·  If I do not receive joint accreditation, and I choose not to apply for accreditation individually through ACCME, ACPE and/or ANCC, then my current accreditations will expire at the currently scheduled expiration date.
Signature

Submit Form and Fee to:

Dimitra V. Travlos, PharmD, BCPS
Assistant Executive Director, and
Director, Continuing Pharmacy Education Provider Accreditation

Accreditation Council for Pharmacy Education
135 South LaSalle Street, Suite 4100
Chicago, Illinois 60603