Test Course Endorsement

Which tier of endorsement would you like to purchase?*
Endorsement is valid until the end of the course. This amount will be returned if endorsement is not granted, less a $100 administrative processing fee.
- Tier 1 - Brand Endorsement
- Tier 2 - Promotional Endorsement
Contact Information
Institution*
Institution Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Course Administrator*
First Last
Course Administrator Phone
Course Administrator Email*
Course Director*
First Last
Course Director Phone
Course Director Email

Will other surgeons direct other specific courses? lf yes, list all names and indicate if they are IPEG Members

(As a reminder: Course must be directed or coordinated by a IPEG member, or have as it's primary faculty at least one IPEG member)

Name	IPEG Member Y/N

Course Title*
Graphics and Mass Email Content
Please upload any graphics or marketing material.
We do not accept PDF documents, so please upload any text in a word document or supply an html file, if you have your own email template.
Drop files here or

Accepted file types: jpg, gif, png, doc, docx, txt, html, Max. file size: 64 MB, Max. files: 5.
Please upload any relevant documentation.
You may also email documentation to [email protected]
Drop files here or

Max. file size: 512 MB.
Additional Course Information
Course Types*
Check all that apply.
- Lecture Only
- Lecture & Hands On
- Other
Average Length of Course (in hours)*
Didactic Portion Hands On Portion
Will CME credits be issued for course?*
If yes, by which organization/institution?*
If no, please explain why.*
Please give a brief description of the classroom facilities, including number of rooms available for lectures, approximate number of seats in each room, etc.*
Please indicate if the facility has an animate laboratory.*
If relevant, please give a brief description of the labaratory facilities, including the number of tables in the lab, veterinarians or lab techs on staff, etc.

Total
$0.00
Payment Type*
- I will pay by Credit Card
- I will pay by check
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Billing Address for Credit Card*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Make check payable to:

IPEG
Attn: Jacqueline Narváez
11300 W. Olympic Blvd. Suite 600
Los Angeles, CA 90064

International Pediatric Endosurgery Group