EORNA ACE APPLICATION FORM

    Complete the form below at least 8 weeks prior your event. If some of the data is not available yet, please send it as soon as possible to complete your request to secretariat@eorna.eu. The official accreditation for your event will be sent once the director of EORNA ACE receives your full request.


    Date (beginning) *

    Date (end) *

      Scientific director information  

    Title

    First/last name *

    Address *

    Zip Code *

    City *

    Country *

    Phone (+ international code) *

    E-mail address *

      Organisational committee director information  

    Name & First name (if different)

    E-mail address (if different)

      Course Director’s Commitment  

    I declare that:

    The scientific programme was developed under my supervision and responsibility, that it is scientifically balanced and without bias

    All faculty and other speakers at this scientific event are aware of, and have agreed, to sign the EORNA ACE disclosure form, and have disclosed any potential conflict of interest that they may have. This must be stated at the beginning of the presentation

    I am aware of the source and form of any commercial funding received to develop this programme

    My signature appears on each EORNA ACE Certificate distributed to all participants to this educational programme

    I am aware of the type of evaluation form participants will have to complete at the end of the programme (EORNA ACE evaluation form or other) and agree to provide the necessary feed-back to EORNA ACE;

    All printed material related to the above-mentioned programme does bear the "EORNA ACE Approved" logo and accreditation statement.

    I accept responsibility for the payment of all fees to EORNA ACE in connection with this application

      Proposed Program  

    Name & Theme of the program *

    Educational aim of the event

    Appropriate participants

    Number of expected delegates

    Upload here your scientific program (included credit hours proposal):

    Upload here your event announcement

    Upload your list of speakers


    Excel or Word file including full name, position, institution, country, areas of expertise and title of presentation

      Declaration on Disclosure  

    In compliance with the EORNA ACE guidelines, the Scientific Committee confirms that all speakers/chairpersons participating in this program have disclosed any potential conflicts of interest or support that might cause a bias in their presentation


    The Organising Committee accepts that it is responsible for ensuring that all potential conflicts of interest relevant to the presentation/event are declared to the audience prior to the CME / CPD activities.


      Event Report Agreement  

    I confirm that a final report will be submitted within 4 weeks after this event.

      I declare that all submitted information is true and that I will send additional information if requested  

    Date of request

    Signature (name) *

    Comments

    The signed original will be sent to the EORNA ACE (secretariat@eorna.eu).

    Please prove you are human by selecting the Cup.

    * = required