Complete this form if event consists of more than one activity and you are: ACCREDITING ACTIVITIES INDIVIDUALLY.

Complete this agreement and submit it to Michigan Pharmacists Association (MPA) a minimum of 45 days prior to the activity date. This joint providership agreement between the MPA and the Hosting Organization defines the relationship between the two parties regarding the activity or event listed below
and is consistent with standards for continuing pharmacy education.

Hosting Organization Information

Please provide contact information for the person responsible for this event or activity. To avoid confusion and to maintain efficiency, please appoint only one point-of-contact.
Name of Contact(Required)
Mailing Address(Required)
ACPE Accredited Proivder(Required)

Activity Information

Please provide information about the activity
MM slash DD slash YYYY
Target Audience(Required)
Program Format(Required)


MPA will accredit programs for pharmacists and/or pharmacy technicians based on the targeted audience identified above. If the event has more than one activity (a.ka. program, session) being offered at the event, you can choose to have activities accredited individually, allowing participants to select the activities they wish to attend, but not requiring them to attend each activity; or the entire education activity can be accredited as one program, requiring participants to attend all activities occurring at the event from beginning to end. This application is for events being accredited individually. Should you want your program activities accredited in their entirety as one program, please select the appropriate application.

Activity Announcement Content

To ensure that all ACPE requirements are met according to the standards for continuing pharmacy education, MPA will provide you with an activity announcement link with all ACPE required information. Please be sure to include this link or all ACPE required information on all of your marketing materials and registration page.
Registration Rates(Required)
ACPE now requires MPA to gather Registration rate information Rate(s): Does this activity require a fee for participation?
Registration Type

Terms of Agreement - Hosting Organization

The Hosting Organization agrees to complete the following assignments and adhere to established deadlines.(Required)
The Hosting Organization agrees to complete the following assignments and adhere to established deadlines.

Terms of Agreement - MPA

The responsibility for assurance of all ACPE criteria rests solely with the Provider; therefore, MPA will be responsible for the following. Note: Business days are Monday through Friday.
Assignment Deadline
Notify Hosting Organization of MPA's intent to accredit PCE activity Maximum 7 business days after receipt of joint providership agreement
MPA will accredit the program a minimum of 35 days before the event Minimum 35 days prior to event
MPA will provide Hosting Organization with an activity announcement link, which will contain all program and ACPE information Minimum35 days prior to event
Prepare evaluations and posttests for each activity and submit program instruction sheet to Hosting Organization Maximum 10 days prior to event
Prepare faculty conflicts of interest statement for each activity and submit to Hosting Organization Maximum 10 days prior to event
Provide Hosting Organization with summary evaluations and posttests, if required by host Minimum 60 days post event
Invoice Hosting Organization for fees due Minimum 60 business days post event
Maintain all records Records will be kept a maximum of six years
On behalf of the Hosting Organization, I agree to adhere to the guidelines and terms of agreement set forth in the joint providership manual, agreement and all supplemental materials. I recognize that MPA may terminate this agreement should documentation not be submitted on time and if any activity appears to be in conflict with MPA's commercialism policy and mission. Moreover, MPA has the authority to decline providing continuing education credit to any participant not meeting attendance requirements set forth.
This is an electronic signature(Required)
Please forward along this Faculty Agreement Link to your presenters. Thank you.
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