CME Activity Request Form

Initiating a Program

Program Requestor

Name*		Title
Institution*		Address*
City*		State*	Select Alabama Alaska Arizona Alabama Arkansas California Colorado Cancelled Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Other Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip*		Office Phone*	Ext
Cell Phone
E-mail*
Name of Primary Contact or Assistant
Same As Above
Name*		Title
Contact Phone*
Contact E-mail*
Preferred Date & Time
First Choice*
Second Choice
Third Choice
Preferred Time	--- AM PM To --- AM PM
Faculty Preference (Click to view faculty) Expert Reviews in Dermatology – Directors Kenneth B. Gordon, MD Professor of Dermatology Northwestern University Feinberg School of Medicine Chicago, Illinois Richard Langley, MD Professor of Dermatology and Director of Research Division of Dermatology Dalhousie University Halifax, Nova Scotia, Canada Kristian Reich, MD, PhD Professor of Dermatology Dermatologikum Hamburg Georg-August-University Göttingen Göttingen, Germany Bruce E. Strober, MD, PhD Associate Professor and Vice Chair of Dermatology Director of Clinical Trials Unit University of Connecticut Health Center Farmington, Connecticut Additional Faculty Jerry Bagel, MD Director, Psoriasis Treatment Center of Central New Jersey East Windsor, New Jersey Kristina Callis Duffin, MD Assistant Professor of Dermatology University of Utah School of Medicine Co-Director, Utah Psoriasis Initiative Salt Lake City, Utah David E. Cohen, MD, MPH Charles C. and Dorothea E. Harris Professor and Vice Chairman for Clinical Affairs Director of Allergic, Occupational, and Environmental Dermatology New York University School of Medicine The Ronald O. Perelman Department of Dermatology New York, New York Jeffrey J. Crowley, MD Bakersfield Dermatology Bakersfield, California Nehal N. Mehta, MD, MSCE, FAHA Director, Inflammatory Risk Preventative Cardiology Heart and Vascular Center University of Pennsylvania Bethesda, Maryland Jeffrey M. Sobell, MD Assistant Professor of Dermatology Tufts University School of Medicine SkinCare Physicians Chestnut Hill, Massachusetts Richard B. Warren, BSc, MBChB, MRCP, PhD Senior Lecturer and Honorary Consultant Dermatologist The University of Manchester Salford Royal Foundation Hospital Manchester, United Kingdom
First Choice*	Select Kenneth B. Gordon, MD Richard Langley, MD Kristian Reich, MD, PhD Bruce E. Strober, MD, PhD Jerry Bagel, MD Kristina Callis Duffin, MD David E. Cohen, MD, MPH Jeffrey J. Crowley, MD Nehal N. Mehta, MD, MSCE, FAHA Jeffrey M. Sobell, MD Richard B. Warren, BSc, MBChB, MRCP, PhD	Second Choice	Select Kenneth B. Gordon, MD Richard Langley, MD Kristian Reich, MD, PhD Bruce E. Strober, MD, PhD Jerry Bagel, MD Kristina Callis Duffin, MD David E. Cohen, MD, MPH Jeffrey J. Crowley, MD Nehal N. Mehta, MD, MSCE, FAHA Jeffrey M. Sobell, MD Richard B. Warren, BSc, MBChB, MRCP, PhD
Third Choice	Select Kenneth B. Gordon, MD Richard Langley, MD Kristian Reich, MD, PhD Bruce E. Strober, MD, PhD Jerry Bagel, MD Kristina Callis Duffin, MD David E. Cohen, MD, MPH Jeffrey J. Crowley, MD Nehal N. Mehta, MD, MSCE, FAHA Jeffrey M. Sobell, MD Richard B. Warren, BSc, MBChB, MRCP, PhD
Please Indicate Higher Priority
Activity Date Faculty
Estimated Number Of Participants
Physicians
Fellows/Residents		Other Clinicians
Room Location (if available)