Council on Optometric Practitioner Education


4340 East West Highway, Suite 401,Bethesda, MD 20814-4411,
(800)-758-COPE, (301)-718-6507, (301)-656-0989


Application for Administrator Qualification

The only requirement for achieving the status of Qualified COPE Administrator is to submit this form to COPE after reading all the information in this document and agreeing to comply with the criteria outlined on the criteria page.

If you have any questions, please call COPE at (301) 718-6507 before submitting this application.

Do not remit any funds when you submit this application form.



1. ADMINISTRATOR:

(i.e. the organization, group, entity, or person(s) assuming overall responsibility for program planning, promotion, on-site administration, and financial management for the event)

Name (as it will appear on all promotional material):

Email Address (optional):

Address:

Address 2:

City:

State:

Zip Code:

Country:


2. CONTACT PERSON:

(i.e. the person who is administratively responsible for the program, typically a program committee chairperson or head of CE)

Dr. Mr. Ms.
Contact Name:
Title:
Email Address (optional):
Phone Number:
Fax Number:


2. PROPRIETARY SUPPORT:

(Please provide a narrative description of any direct or indirect support you receive from a for-profit entity which could reasonably be considered to have an impact on the content of your program. No financial d ata are requested. If an exhibition is part of your program, provide some idea of the number of exhibitors. Of specific interest is any support provided by a company for a particular aspect of your program)


4. CERTIFICATION OF COMPLIANCE:

By submitting this form you certify that the Administrator identified above agrees to comply with the COPE Criteria for Administrator Qualification (see criteria page).

5.

If you are mailing in courses for review, pleae down load a copy of the Administrator Qualification form and include it with the Applications for Course Qualification.
To download a copy of the Administrator Qualification Form click here, and mail the completed form with the course forms.

Do you wish to be copied with all correspondence to the Principal Instructor regarding the course(s) being mailed? (check one)

Yes. No.

If application materials are missing, do you wish COPE to contact you or the Principal Instructor first? (check one)

Contact me:
Contact the Principal Instructor:
If we are to contact you, please include a postal address, email address, phone or fax number, etc. that we should use, or enter "Contact Person" to indicate we should contact the above-named administrator:


6. NAME OF PERSON COMPLETING FORM:


Dr. Mr. Ms.
Name:
Date:


Comments:


SEND COURSES TO BE EVALUATED TO:


COPE®
4340 East West Highway, Suite 401, Bethesda, MD 20814-4411

DO NOT REMIT ANY FUNDS WHEN YOU FILE THIS APPLICATION

NOTE: A CE Event Notification Form will be sent to you once Administrator Qualification status is conferred.




Suggestions to: (Ernie Patterson)
CGI: Jos Purvis WEB: Ernie Patterson