PELI Advanced Enrollment (1) Step 1 of 5 20% Questions about the course? Please visit www.hanleyleadership.org Other questions? Please contact Judiann Smith at judiannsmith@hanleyleadership.org or 207-553-9852. This activity has been planned and implemented in accordance with the Essentials and Standards of the Maine Medical Association Committee on Continuing Medical Education and Accreditation through the partnership of Maine Medical Education Trust and Daniel Hanley Center for Health Leadership. The Maine Medical Education Trust is accredited by the Maine Medical Association to provide CME activities for physicians. Full completion of the PELI Advanced course yields 80 Category One CMEs.Name* First Last Credentials Organizational Affiliation* Position* Years of Professional Experience* Years of Leadership/Management Experience* Business InformationBusiness Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Business Phone*Extension Business Email* Home InformationHome Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone*Phone Number Type (Home, Mobile, etc)* Home Email* Your Preferred Contact Method* Any Dietary Restrictions?* Emergency Contact Name* First Last Emergency Contact Relationship* Emergency Contact Phone* Personal ProfileCVPlease attach a current resume or curriculum vitae.Max. file size: 300 MB.Strengths*Please describe your unique strengths, interests, background, attributes or dimensions of diversity that you will bring to the cohort.Gain*Please briefly describe what you hope to gain for yourself and/or your organization from the PELI Advanced Course. If you have completed other leadership development courses, please tell us about them.Enrollment Fee - $100 A non-refundable enrollment fee is required from all perspective enrollees. Your enrollment will not be considered complete until the fee is received.Enrollment Fee* Pay Now via Paypal Invoice Me PELI Advanced Enrollment FeeIf you prefer, you can mail a check for $100 to Daniel Hanley Center for Health Leadership PO Box 4606 Portland, ME 04112
