5 <strong>Application</strong>AADE12 Annual Meeting & Exhibition<strong>Product</strong> Theatres <strong>Application</strong> and GuidelinesSection 3: Speaker ListIt is recommended that the program include no more than 3 speakers.SpeakerNameTitle(s)CredentialsSpeakerNameTitle(s)CredentialsSpeakerNameTitle(s)CredentialsModerator (if applicable)NameTitle(s)Credentialswww.diabeteseducator.org/corpsym
6 <strong>Application</strong>AADE12 Annual Meeting & Exhibition<strong>Product</strong> Theatres <strong>Application</strong> and GuidelinesSection 4: Program GoalsOverall Program Goal(s) Check all applicable boxesEstablish innovative partnerships that promote chronic disease management through measurable outcomesDescribe new methodologies used to support and enhance the quality of patient centered careDemonstrate how to enhance the role of the diabetes educator in a time of innovative change.Section 5: Due Date and Payment Agreement FormThe Program Administrator agrees to adhere to the due dates stated below (please initial each item):Thursday, March 1, 2012Completed applicationMonday, April 2, 2012Full application feeSponsor logo due to AADE (EPS format preferred)Friday, June 1, 2012Final date to request additional audio visual (late requests subject to additional fees)Additional Meeting room request form and fee deadlineRequests for customized evaluations due Name badges (up to 8)By signing below I hereby agree that I have received and read the AADE <strong>Product</strong> Theatres <strong>Application</strong> and Guidelines,and that all of the information contained in this application is true and correct to the best of my knowledge.Signature of Program AdministratorDatePayment InformationThe following payment options are accepted:Check: Make payable to: American Association of Diabetes EducatorsWire Transfer: Remit payment to: AADE, 200 W. Madison, Suite 800, Chicago IL 60606. For further remit optionsand/or questions, please contact Tina Rachuy (312) 601-4832 or Kazumi Mochizuki (312) 601-4840Credit Card payment will not be accepted.<strong>Application</strong> FeeAfternoon <strong>Product</strong> Theatre Wednesday, August 1, 2012 3:00 p.m. – 4:00 p.m.* $60,000Morning <strong>Product</strong> Theatre Thursday, August 2, 2012 6:30 a.m. – 7:30 a.m.* $60,000Total Enclosed $ *Times are subject to change.Submission InstructionsPlease email a completed digital application to jbellan@aadenet.org and mail a printedand signed copy of the application and corresponding application fees to:American Association of Diabetes EducatorsAttention: Jackie Bellan, CMP, Meeting Planner200 W. Madison Street, Suite 800, Chicago, Illinois 60606Office: (312) 601-4876 • Fax: (312) 601-4891www.diabeteseducator.org/corpsym
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