PELI APP Enrollment Form Step 1 of 4 25% This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the Maine Medical Education Trust and (name of nonaccredited provider). The Maine Medical Education Trust is accredited by the Maine Medical Association Committee on Continuing Medical Education and Accreditation to provide continuing medical education for physicians. Full completion of the PELI APP course yields 40 AMA PRA Category 1 Credit(s)™. Questions About the Course? Please contact Judiann Smith at judiannsmith@hanleyleadership.org or 207-615-6253 or Janell Lewis at jlewis@hanleyleadership.org or 207-415-0666Name First Last Credentials Organization Affiliation Position Years of Professional ExperienceBusiness Address Street Address Address Line 2 City 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 State ZIP Code Business PhoneExtension Business Email Home Address Street Address Address Line 2 City 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 State ZIP Code Alternate PhonePhone TypeMobile PhoneHome Phone Additional InformationPreferred Contact Method (Weather)Mobile PhoneHome PhoneBusiness EmailHome EmailDietary Restrictions Emergency Contact Name First Last Emergency Contact Relationship Emergency Contact Phone Personal ProfileResume or Curriculum VitaeMax. file size: 300 MB.Please attach a current resume or curriculum vitae.GainPlease briefly describe what you hope to gain for yourself and/or your organization from the Provider Executive Leadership Institute - Advance Practice Professional APP Foundational Course.An enrollment deposit is required from all prospective enrollees. If the minimum number of 12 participants do not enroll, the enrollment deposit will be refunded.Enrollment Deposit* Invoice me for the enrollment deposit fee Pay with check If paying by check, please send to: Daniel Hanley Center for Health Leadership PO Box 4606 Portland ME 04112PELI APP Enrollment Deposit Payment Price: CAPTCHA
