Agency Request Form (New Agencies Without MCAs Only)

If you are new to American CME and did not have an agency account previously on our old site, please fill out this form. Agencies that had accounts previously do not need to fill out this form. Thanks!

Agency Name *

Provide full name of agency

Parent Organization

Provide name of affiliated Medical Control Authority (MCA) if you have one. Skip this field if not.

State or Province *

In what US state or Canadian province are you located?

Organization Type *

• Fire Department
• Ambulance Service
• Public Safety Department
• Airport
• School
• Other

If agency type is Other, what type of agency?

Link to agency logo or homepage showing logo

Email us a 250 x 250 pixel png file logo or provide a link to it here, and we'll resize it.

Group Leader

Provide your name if you will be the group leader or provide the name of the person who will manage group enrollment. (A group may have other Team Leaders but only one Group Leader).

Group Leader Email *

Provide the email address of the person who will be the group leader. This may be your email.

Number of Sub Accounts (Personnel) *

How many members will you have in your group?

Do you plan to assign Free Courses or Free Custom Education Courses to your group? Yes or No.

Free Courses are available to assign to your group. American CME does not issue State or NREMT CE credit for Free Courses except in New Jersey.

Do you plan to purchase CAPCE subscriptions for your agency personnel? If so, how many seats?

A custom membership plan for your organization will be created based on the number of personnel. The agency discount is 30% off regular price per person.

Email *

Phone

We'll email or call if we have questions. Thank you!

Submit