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Texas 2010

October 7-11, 2012
Dallas, TX

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Application

Fill out the information below and submit to CCMM. Upon submission you will receive a list of the information the Credentials Committee will need in order to evaluate your application (Eligibility).

Mail the information to CCMM, along with your $125 non-refundable application fee.

If you have any questions, please contact Tina Ramsey (tramsey@acpe.org) or Ruth Mikula (rmikula@acpe.org).

First Name *
Last Name *
I am a	MD DO
Organization
Title
Street
City
State
Zip Code
Telephone
Fax
Email *

(Required Field *)

Clinical Board Certification

Must be or have been board certified in a clinical specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association. Must have been in good standing if you chose not to renew board certification.

Board Certified in:

Education Requirements

A. I have completed 150 hours of management education (116 hours of tested core courses plus 34 hours of tested elective managmenet courses through ACPE)

OR

B. I have completed an accredited graduate management degree (i.e. MBA, MMM, MS, MHA, MPH, etc.) Attach Transcripts.

Institution
City
State
Degree
Date Completed

I understand that in order for my CPE application to be accepted, I must be of good moral character and be willing to abide by the Articles, Bylaws and Rules of the Certifying Commission in Medical Management.

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