1	Name of program
2	Format of program (check all that apply)
	Workshop Class Lecture Meeting/conference presentation Single course Series of courses Online format Video format Audiotape format Correspondence course
	Other
3	List of courses in program (if this is a series of courses).
	1
	2
	3
	4
	5
	6
	7
	8
4	Faculty required (briefly list major qualification, e.g., MD, RN, etc.)
5	Location of program, if applicable (university, hospital, etc.)
6	Intended audience (check all that apply)
	Physician Nurse Academic Researcher Allied health care worker Other professional Student Patient/caregiver
7	Admission requirements
8	Textbook/other materials
9	Tuition per person, if applicable
10	Degree or certification granted
11	Name of program sponsor/author
12	Program Contact Information
	Name
	E-mail
	Telephone Number
	Fax Number
	Address 1
	Address 2
	Address City
	Address State/Province
	Address Zip/Postal Code
	Address Country
13	Website address of program
14	Brief description of program
15	Your Contact Information
	Name
	E-mail
	Telephone Number
	Fax Number
	Address 1
	Address 2
	Address City
	Address State/Province
	Address Zip/Postal Code
	Address Country
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