Cosponsorship is provisional upon receiving all required information and fees. This form must be submitted with the required administrative fee at least 60 days prior to program date.

1.	Cosponsoring Organization:* (Must be approved by CEI prior to this application)

2.	CE Cosponsor Representative:*
	Name:   Address:   City/State/Zip:   Telephone #:   Fax #:

3.	Cosponsor Contact Email:*

4.	Program:*
	Title:   Date:   Location:

5.	Faculty and Qualifications:*
	Name with Credentials:   Title:   Organization:

6.	If more than one speaker, please provide the requested information below:

7.	List other organizations, agencies or corporations assisting financially or cosponsoring program presentation (if applicable):* How was this financial support secured? (ex. online grant request, etc.) Please also indicate if support is in progress.

8.	Did you have independent control to determine the topic, learning objectives and content of the program?
	-- None --Yes No

9.	If no, please explain.

10.	Will off label use of medications be discussed?*
	-- Please Select --Yes No

11.	Number of CEUs requested: * (0.1 CEU equals 1 contact hour and 1.0 CEU equals 10 contact hours.)

12.	Is this program:*
	Knowledge-based (transmits knowledge) Application-based (requires application of information learned within the program time frame, eg. demonstration of knowledge through a patient case)

13.	Target audience:* * If programming pertains to both pharmacists and pharmacy technicians, separate learning objectives are needed.
	Pharmacists:    Pharmacy Technicians    Student Pharmacists    Other, please specify

14.	Anticipated number of participants:*

15.	Anticipated number of pharmacists expected to request CE credit:*

16.	Anticipated number of technicians expected to request CE credit:

17.	Restricted: [Not open to ALL] (Note: If this is not a restricted program, your program will be advertised nationally on the Pharmacists’ Learning Assistance Network {P.L.A.N.} – ACPE’s CE program database.)
	-- None --Yes No

18.	Registration fee/participant: (if applicable)

19.	Registration/tuition fee includes: (even if $0.00 for participants) (ex. Meal, handouts, CE credits, etc.)

20.	Please list or send a time schedule of program events (i.e.: 6:00 p.m. Social; 7:00 p.m. CE Program; 8:00 p.m. Business Meeting. Please be sure to list the time of day):

21.	Program Goal: (a statement indicating the overall goal of the program):

22.	Educational Objectives for Pharmacists: “At the completion of this program, the participant should be able to:” (Action words describing what the participant should learn. Please list approximately 5 objectives per contact hour. For more information on writing learning objectives, see “Developing Learning Objectives”.)

23.	Educational Objectives for Pharmacy Technicians: “At the completion of this program, the participant should be able to:” These must be at the level and ability of a pharmacy technician. (Action words describing what the participant should learn. Please list approximately 5 objectives per contact hour. For more information on writing learning objectives, see “Developing Learning Objectives”.)

24.	Describe plans for assessing learning of the material presented (ex. evaluations, post-tests, etc.):

25.	Describe plans for allowing pharmacists and/or pharmacy technicians to assess their own learning of the material presented (ex. pre-test, post-test, case study, question & answer, etc.):

26.	Promotional Piece:*
	I am planning to develop my own promotional piece and will provide CEI with a copy of it and the Program Announcement Literature Checklist for approval 14 days before final production. I will send a copy of my promotional piece and the Program Announcement Literature Checklist for you to approve.

27.	How will the following be sent to CEI, 8515 Douglas Ave., Ste 16, Des Moines, IA 50322?* THESE MUST BE RECEIVED BY CEI 30 DAYS PRIOR TO THE PROGRAM DATE IN ORDER TO ALLOW ENOUGH TIME FOR OUR PEER-REVIEW PROCESS. IF CHANGES NEED TO BE MADE, YOU WILL BE NOTIFIED AT LEAST 14 DAYS BEFORE THE PROGRAM.
	E-mail   Mail Program agenda with full schedule     Copy of the program handouts & presentation     CV or resume for each presenting faculty     Pre- and/or post-test and other pertinent program information     Program Announcement Literature

28.	How will the following fees be sent to CEI, 8515 Douglas Ave., Ste 16, Des Moines, IA 50322?
	Mail   Online Adminstrative Fees     CE Statement Fees

	Please refer to the Timeline/Checklist for Program Approval for the required information due in to CEI prior to the program and after the program.

29.	I agree to take responsibility for the information provided here-in and the guidelines established for cosponsorship by The Collaborative Education Institute.*
	-- Please Select --Yes No