Industry Supported Satellite Symposium Application

Only Satellite Symposia programs offering certified continuing education (CE) are allowed. Accreditation is the organizer’s responsibility. All Satellite Symposia must comply with the Accreditation Council for Continuing Medical Education (ACCME) Standards for Integrity and Independence in Accredited Continuing Education.

The symposium organizer must complete the Satellite Symposium application to indicate their intent to organize a symposium and rank their preferred time slot if requesting a live in-person program.

All applications will be reviewed by the ACTRIMS Scientific Program Committee.

The Scientific Program Committee and the accredited CE provider adhere to the Standards for Integrity and Independence as defined by ACCME.

Commercial Supporter *

Certified CE Provider *

Contact Name *

Title *

Phone Number *

Email Address *

Street Address *

Address Line 2

City *

State/Province/Region *

Zip/Postal Code *

Country *

Preferred Format *

Live In-Person

Pre-recorded On Demand

If requesting a live in-person symposium, please provide your order of preference with 1 being most preferred slot and 4 being your least desired slot.

	Thursday, February 29; 8:00 - 9:00 am
	Thursday, February 29; 12:20 -1:20 pm
	Friday, March 1; 8:00 - 9:00 am
	Friday, March 1; 12:20 - 1:20 pm

Satellite Symposium Faculty

The ACTRIMS Forum Satellite Symposia guidelines require symposia to be well balanced and faculty should be chosen from emerging as well as more experienced investigators and clinicians. Diverse faculty representation regarding gender, race, and ethnicity is also required. Please list your symposium faculty below ensuring these policies are adheared to.

Symposium Chair/Moderator #1 *

	Chair/Moderator #1
Name & Credentials	Chair/Moderator #1
Title	Chair/Moderator #1
Institution	Chair/Moderator #1
City, State	Chair/Moderator #1
Email	Chair/Moderator #1

Symposium Chair/Moderator #2 (if applicable)

	Chair/Moderator #2
Name & Credentials	Chair/Moderator #2
Title	Chair/Moderator #2
Institution	Chair/Moderator #2
City, State	Chair/Moderator #2
Email	Chair/Moderator #2

Symposium Speaker #1 *

	Speaker 1
Name & Credentials	Speaker 1
Title	Speaker 1
Institution	Speaker 1
City, State	Speaker 1
Email	Speaker 1

Symposium Speaker #2 (if applicable)

	Speaker 2
Name & Credentials	Speaker 2
Title	Speaker 2
Institution	Speaker 2
City, State	Speaker 2
Email	Speaker 2

Symposium Speaker #3 (if applicable)

	Speaker 3
Name & Credentials	Speaker 3
Title	Speaker 3
Institution	Speaker 3
City, State	Speaker 3
Email	Speaker 3

Symposium Speaker #4 (if applicable)

	Speaker 4
Name & Credentials	Speaker 4
Title	Speaker 4
Institution	Speaker 4
City, State	Speaker 4
Email	Speaker 4

Satellite Symposium Program

Symposium Title *

Symposium Description *

0/1000 characters

Needs Assessment *

0/1000 characters

Learning Objectives or Educational Goals *

0/1000 characters

Agenda *

0/1000 characters

Credits Earned *

Has your organization hosted a Satellite Symposium at an ACTRIMS Forum in the last three years? If so, please explain how your proposed 2024 symposium differs from previous symposia. *

0/1000 characters

Supporters are strongly encouraged to enhance the food and beverage during the breakfast and lunch slots. Please confirm your plan to arrange additional food and beverage. *

Yes

Please list any notes or comments for the Scientific Program Committee to be aware of during their review process below (e.g., status of faculty invitations, etc.).

0/1000 characters

Rules, Regulations, Terms & Conditions

By submitting a Satellite Symposia Application, the Industry Supporter agrees to the Rules, Regulations, Terms & Conditions (the “Rules”) outlined in the ACTRIMS Sponsorship Prospectus as well as all supporting documentation, including, but not limited to the Industry Supported Satellite Symposium Manual. The Industry Supporter’s submission of a Satellite Symposia Application is an offer to ACTRIMS to sponsor a symposium and, a binding contract between the Industry Supporter and ACTRIMS will only be formed when written confirmation of acceptance is sent by ACTRIMS to the Certified CE Provider. ACTRIMS reserves the right in its sole discretion to refuse to accept any Satellite Symposia Applications. *

Agree

Signature: The person signing the Satellite Symposium Application on the Certified CE Provider's behalf shall be deemed to have full authority to do so and shall have no right to claim against ACTRIMS that such person or persons did not have such authority. *

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