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Sponsored Luncheon Application Form
Please complete this application form and read the Terms and Conditions for sponsored luncheons at the Ajax Harwood Clinic. Sponsored Luncheons are by invitation only.
Email address *
Today's Date: *
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Please write your name:
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Best phone number to reach you at: *
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Fax number:
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Company Name: *
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Drug Name: *
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When was the last time your company came to this clinic to sponsor a luncheon?
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Please provide a short description of the topic you will be presenting on: *
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Will there be a speaker (Health Care Professional)? If yes, please write the speaker's name and credentials.
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Is this a Continued Medical Education (CME) accredited program? *
If this is not a CME accredited program, would your company be interested in sponsoring a journal club? *
Is your company interested in supporting initiatives or research in patient education and empowerment? *
Is your company interested in supporting patient care quality improvement initiatives? *
Have you read and the Sponsored Event and Luncheon - Terms and Conditions? (Can be found here: https://docs.google.com/document/d/1etThQiCNu4LBHpjCzjxSWGEduJBhWb8LQG98Xr1Qr04/edit?usp=sharing ) *
Please provide any additional comments you may have:
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