ActivityOverviewPage1

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		Please provide the following contact information for the Course Director.
Course Director *
Organization *
Street Address
City
State/Province
Zip/Postal Code
Work Phone *
Fax Number
E-Mail *
URL

Please provide the following contact information for the Department Coordinator.

Department Coordinator
Organization
Street Address
City
State/Province
Zip/Postal Code
Work Phone
Fax Number
E-Mail
URL

This activity is affiliated with: *

UTMB Galveston Affiliation

UT Houston Affiliation

Other Affiliation

Entity submitting overview (Department, company, society, institution):
Event Title
Event Location
Justify the need for the educational content of this activity, with at least one published source (for example: National Goal to reduce breast cancer deaths per Healthy People 2010) * Note: Please list minimum of one (1) published source.

For more information on published resources please click here.

Start Date: (mm/dd/yyyy)
End Date: (mm/dd/yyyy)
Projected number of participants: *
Purpose: (Hold Ctrl and click to select multiple options)
Accreditation Requested: (Hold Ctrl and click to select multiple options) *
Tentative CE Hours:

Event Type: *