Harvey Pediatric Clinic - 2017 Merit Award 2017 Merit Award

Event Submission

Event Submission Form

Type of Event*
- CEU
- Social
EVENT NAME*
Date of Event*
Start Time

: HH

MM
End Time

: HH

MM
Location/Venue of Event
include complete address of location
Event Description
Estimated # of Attendees
If Allied Provided CEU, provide name of Allied Company Presenting below:
Is the Allied Presentation accredited with AIA National
- Yes
- No
Who will be submitting attendance to AIA National transcripts?
- AIA Arkansas
- Allied Company Listed Above
Sponsor Information
List all Allied(s) Sponsoring Event. One sponsor per row, click + to add
Allied Company Name Sponsorship Amount $
TOTAL Sponsorship $
Section/Committee Information
Section/Committee Submitting Event*
- Central
- East
- Fort Smith
- Northwest
- Diverstiy / WIA
- Emerging Professionals
Cost incurred by Section/Committee
Reimbursement Requested?
- Yes
- No
if yes, upload receipts below
Receipt(s) for Reimbursement Upload
Drop files here or
Contact Name*
First Last
Phone
Email*
Date Submitting Event

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