cme enrollment form

CME ENROLLMENT FORM Program Description and Objective: The Journal of Urology ® Home Study Course is a comprehensive learning activity developed by a team of educators, academicians, and clinicians. After completing the program, urologists will be able to demonstrate an increase in or affirmation of their knowledge of clinical medicine. They will also be able to evaluate the appropriateness of clinical data and apply it to their practice and to the provision of patient care. Program Format: Each of the 12 tests consists of 5 questions focusing on 5 specific articles in The Journal of Urology. ® Upon receipt of payment, the subscriber will receive 12 answer sheets. Completion of each test with a minimum passing grade of 80% will qualify the participant for 2 hours of continuing medical education (CME) credits. Certificates of Completion will be mailed to subscribers each year in January. Accreditation The American Urological Association Education and Research, Inc. ® is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. This CME activity was planned and produced in accordance with the ACCME Essentials. Continuing Medical Education Credit Hours The American Urological Association Education and Research, Inc. ® designates this education activity for a maximum of 24 hours of category 1 credit towards the AMA Physician’s Recognition Award. Each physician should claim only those hours of credit that he/she actually spent on the educational activity. This CME category 1 credit activity is valid for a 3-year period from date of publishing. See page 671 for questionnaire The Journal of Urology ® Home Study Program Registration Form Volume # $60 subscription cost covers two consecutive volumes beginning with Vol. 161 Volume # 24 Category 1 credit hours Name: Address: City: State: Zip: Daytime Phone: ( ) ( ) Check enclosed for $ payable to: American Urological Association Education and Research, Inc. ® Charge to ( ) VISA ( ) MasterCard ( ) AMEX Card Number: Exp. Date: Signature: Please mail or fax registration form to: American Urological Association Education and Research, Inc. ® P.O. Box 201820 Houston, Texas 77216-1820 Telephone: 1 (800) 282-7077 Fax: (713) 622-2898 6 8 Office of Education 9 7 1118

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Program Format: Each of the 12 tests consists of 5 questions focusing on 5 specific articles in The Journal of Urology.®

Upon receipt of payment, the subscriber will receive 12 answer sheets. Completion of each test with a minimumpassing grade of 80% will qualify the participant for 2 hours of continuing medical education(CME) credits. Certificates of Completion will be mailed to subscribers each year in January.

AccreditationThe American Urological Association Education and Research, Inc.® is accredited by the Accreditation Council forContinuing Medical Education (ACCME) to sponsor continuing medical education for physicians. This CME activity wasplanned and produced in accordance with the ACCME Essentials.

Continuing Medical Education Credit HoursThe American Urological Association Education and Research, Inc.® designates this education activity for a maximum of24 hours of category 1 credit towards the AMA Physician’s Recognition Award. Each physician should claim only thosehours of credit that he/she actually spent on the educational activity. This CME category 1 credit activity is valid for a3-year period from date of publishing.

See page 671 for questionnaire

The Journal of Urology® Home Study Program Registration Form

Volume #

$60 subscription cost covers two consecutive volumes beginning with Vol. 161Volume # 24 Category 1 credit hours

Name:

Address:

City: State: Zip:

Daytime Phone: ( )

( ) Check enclosed for $ payable to: American Urological Association Education and Research, Inc.®

Charge to ( ) VISA ( ) MasterCard ( ) AMEX

Card Number: Exp. Date:

Signature: