TEST Submit Medicare Sales & Educational Events

Use this form to submit details for any upcoming Medicare sales or educational events so they can be shared and tracked for compliance.

Submit your event details before the event takes place, and submit attendee counts afterward using the same form.

Has your event taken place already? Yes

Event Information (Pre-Event)

*Required Fields

Contract Number

Presenter Name

Presenter Contact Phone Number

Event Date

Please enter a valid Date, mm/dd/yyyy

Event Start Time

Event Information (Post-Event)

*Required Fields

Contract Number

Presenter Name

Presenter Contact Phone Number

Event Date

Please enter a valid Date, mm/dd/yyyy

Event Start Time

Location Details

*Required Fields

Venue Name

Venue Phone Number

Venue Address

Venue Address Line 2

Venue City

Venue ZIP

Contact Information

*Required Fields

Representative/Agent Name

Agent NPN

Brokerage Firm/Agency

Additional Information

*Required Fields

Expected Number of attendees

Number of attendees

Special Notes or Instructions

Review and Submit

Contract Number : Edit

Presentation Language : Edit

Other language (if applicable) : Edit

Event Type : Edit

Event Name : Edit

Presenter Name : Edit

Presenter Contact Phone Number : Edit

Event Date : Edit

Event Start Time : Edit

Contract Number : Edit

Event Name : Edit

Presenter Name : Edit

Presenter Contact Phone Number : Edit

Event Date : Edit

Event Start Time : Edit

Facility Type : Edit

Other venue (if applicable) : Edit

Venue Name : Edit

Venue Phone Number : Edit

Venue Address : Edit

Venue Address Line 2 : Edit

Venue City : Edit

Venue State : Edit

Venue ZIP : Edit

Venue County : Edit

Representative/Agent Name : Edit

Agent NPN : Edit

Brokerage Firm/Agency : Edit

Expected Number of attendees : Edit

Number of attendees : Edit

Special Notes or Instructions : Edit

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