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COPE CE Administrator/Provider Application

Organization Information
Organization Name: (full legal name)
Chief Executive Officer of Organization:
Address:
City:
State/Province/Jurisdiction:  
Zip:
Country:
Website:
Phone Number:
Fax Number:
What is the scope of your Organization? Local State National
Regional/Multi-State Other
If You Chose Other, Please Explain:
Does the Organization have IRS 501c status? Yes    No
If yes, attach a copy of the IRS notification letter
Is the Organization a member of the Association of Schools and Colleges of Optometry (ASCO)? Yes    No
If yes, do you also submit events for CE courses that are not sponsored by ASCO? Yes    No

Organization Structure
The following section is intended to collect information about your organization's corporate structure. COPE needs to ensure your organization is not a commercial interest (i.e. any entity producing, marketing, reselling, or distributing health care goods or services consumed by, or used on, patients. Providers of clinical service directly to patients are not considered a commercial interest.)

Some organizations are automatically exempt from COPE's definition of a commercial interest, including government organizations, non-health care related companies, liability insurance providers, health insurance providers, group optometric practices, for-profit hospitals, for-profit rehabilitation centers, for-profit nursing homes, blood banks, diagnostic laboratories. NOTE: 501c organizations are screened for eligibility. Those that advocate for commercial interests as a 501c organization are not eligible to become COPE Approved Administrators/Providers.
Select a response if any of the following exemptions is applicable to your organization.

You must submit an answer for either number 1 or number 2.
1. My organization is exempt from COPE's definition of a commercial interest because it is a:
2. My organization is not exempt from COPE's definition of a commercial interest. (You must answer all of the following questions so that COPE can assess your organization's eligibility.)
A. Does your organization produce, market, resell, or distribute health care goods or services consumed by or used on patients? Yes No
Explanation:
B. Is your organization owned or controlled by an entity that produces, markets, resells, or distributes health care goods or services consumed by, or used on patients? Yes No
Explanation:
C. Is there anywhere within the larger corporate structure of your organization an entity that produces, markets, resells or distributes health care goods or services consumed by or used on patients? Yes No
D. If you answered yes to item c above, please specify the organizational and procedural relationship of the commercial interest(s) to your organization.
Explanation:
E. Are there organizational and procedural safeguards (corporate firewalls) in place to ensure that the CE entity is separate from any commercial interest listed in item d above? Yes No
F. If you answered yes to item e above, describe and attach an organizational chart to depict the organizational and procedural safeguards in place to ensure that the CE entity is separate from any commercial interest within the larger corporate structure of your organization.
Description:
Organizational Chart:

Additional Comments:

Organization Contacts
Primary Contact First Name:
Primary Contact Last Name:
Primary Contact Title:
Primary Contact Phone:
Primary Contact Fax:
Primary Contact E-Mail:

Other Contact First Name:
Other Contact Last Name:
Other Contact Title:
Other Contact Phone:
Other Contact Fax:
Other Contact E-Mail:

Other Contact First Name:
Other Contact Last Name:
Other Contact Title:
Other Contact Phone:
Other Contact Fax:
Other Contact E-Mail:

Other Contact First Name:
Other Contact Last Name:
Other Contact Title:
Other Contact Phone:
Other Contact Fax:
Other Contact E-Mail:

Before your organization can be accepted as a COPE Approved Administrator/Provider, your understanding a commitment to abide by COPE's standards must be confirmed.
  By checking this box, my organization acknowledges that we have read and understand all of COPE's rules
  By checking this box, my organization agrees to adhere to all of COPE's rules in all aspects of our CE activities
 
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