Activity Title (must be at least 45 minutes in length to be acceptable for Maintenance

purposes)
MAGI Annual Conference
Advances in Diabetes Treatment
Investigator Meeting
Pain Management for Stage IV Cancer
Good Clinical Practice Update

Research
Specific
17

Other
Healthcare

EXAMPLES

Continuing
Involvement

Course Provider
CME
CBRN
Other
CME
CME

Total
The information I have submitted on this application is complete and correct. I understand that false information may be cause for denial or loss of certification.
I have submitted _______ total eligible contact hours/points to maintain my (circle all that apply) CCRA CCRC CCTI CPI credential(s).

Print Name______________________________________________

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Signature_________________________________ Date____________

Date(s)
5/19/13
6/27/13
1/13/14
12/5/12
12/13/12