Request For Cme Certificate/transcript
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1Request for CME Certificate/Transcript
Date of Request
Name
(Print Clearly)
Credentials: (circle)
MD, PhD, PsyD, DO, PA, CNM, RN, Other
Address
Facility/Department
Box #
Telephone
Cell / Pager / Work Phone #
Request Information
Transcript(s) ($20 per Academic year)
Title of Activity, Date of Occurrence
Presented by (Hospital/Department)
Certificate(s) ($20 per conference)
Title of Conference, Date of Occurrence
Presented by (Hospital/Department)
Payment Information
Check # __________________________
Cash/Paid in person ________________
Please charge my credit card:
Visa
MasterCard
Discover
Amount Authorized $__________________
Cardholder’s Name (as it appear on card): ___________________________________________________________________
Card Number # _____________________________________________________ Expiration Date: _____________________
Signature _______________________________________________________________________________________________
I hereby authorize SUNY Downstate to charge my credit card for the amount indicated above.
Choice of Delivery:
Will Pick Up
Fax# _____________________
Mailbox # __________
Send To:
Return this form to Box 1244 or fax to (718) 270-4563. The $20 processing fee can be paid at the Bursar office or you may forward your
payment to OCME at 450 Clarkson Ave, Box 1244 Brooklyn, NY 11203. Make check payable to SUNY OCME.
Please allow two weeks for a reply to your request, and indicate your choice of delivery of your request on the form. Transcripts and certificates
will be forwarded upon receipt of your fee. If you have any questions, please refer your calls to (718) 270-2422.
For Office Use Only:
Fee Paid:
Yes
Pending
Mail / Pick up Date ___________________________
Processed by: ________________________________________________________ Date: ____________________________
Rev. 11/2006
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