Filling out an application for a CPE is a three-step process. First, fill out the form below as completely and accurately as possible. When you submit, you will be sent to a page outlining the information that needs to be mailed to CCMM. If you have any questions or comments, please contact Tina Ramsey tramsey@acpe.org or Ruth Mikula rmikula@acpe.org

First Name:
Last Name:
Degree	MD DO
Organization
Title
Street Name:
City:
State:
Zip Code:
Telephone:
Fax:
E-Mail Address:

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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:

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Education Requirements A. I have completed 150 hours of management education (113 hours of tested core courses plus 37 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 and a copy of the course description as printed in school catalog or graduate school brochure.

Institution:
City:
State
Degree:
Date Completed:

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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.