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The information necessary to plan and develop the proposed CME series. Completion of all sections of this form is necessary to meet accreditation requirements. Please attach all required documentation. Applications without this information and signatures of course directors and the department chairperson will be returned. Program Identification: Activity Title: Affiliation: IFH IAH IFOH IMVH IHS Other (describe) Tue Wed Thur Activity Date: Day(s) of Week Held: Time(s): Sun Start Tim.

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