1. Name, Title, and Contact Information of Authorized Staff Member submitting the Application:

2. Name of Organization conducting the educational activity:

3. Website of Organization conducting the educational activity:

4. Full Name of the educational activity:

5. Date(s) of the educational activity:

6. Location and Venue of the educational activity:

7. Is this educational activity being organized / conducted jointly with any other organization / institution / company?

___yes ___no

8. If yes, list the partnering organizations / institutions / companies and describe their involvement:

9. What educational accreditation will be provided to the attendees of this educational activity?

10. Explain the need, purpose, and value of ISHLT Endorsement for your organization and for this educational activity:

11. Describe the professional specialties and level(s) of expertise of the target audience for which this educational activity is designed:

12. Is registration open to all or invitational? ___Open to all ___Invitational

13. Is the scientific and educational content of this activity in compliance with the Declarations of Helsinki and Istanbul and with ISHLT’s Ethics Statement?

___yes ___no

14. If any industry employees are presenting content at this educational activity, please provide information about their unique qualifications that justifies their involvement and your process for ensuring that such presentations are not biased:

15. Explain how a balanced view of the available therapeutics / devices being presented will be provided to the audience:

16. Describe the policies in place to collect information regarding potential conflicts of interests of speakers, chairs, and program development committee members, and the method of mitigating any potential bias or industry influence over content:

The following MUST accompany your Application for Endorsement:  An Application Fee of US $200, payable in US dollars  Meeting Registration Form  Exhibitor Application Form and Prospectus/Policies  Complete List of Commercial Support Opportunities and Prices  Complete Final Program, including Program Development Committee members, speakers, and chairs, with institutional affiliations and professional degrees. For meetings conducted in a language other than English, an English translation of the Final Program must be submitted  Complete List of Companies providing financial or in-kind support for the meeting or for individual program committee members, speakers, and chairs  list of all of the social media accounts (Facebook, Twitter, LinkedIn, etc.) where the educational activity will be promoted, and instructions on how to follow them

If endorsement is granted, the following must be submitted within 90 days of completion of the educational activity:  Summary of post- meeting evaluation results (if any)  List of delegates, including full name, institution, mailing address, email address, professional specialty  List of exhibitors, including contact name, company name, mailing address, email address  Final list of industry sponsors/supporters  List of other organizations that endorsed the meeting  Copies of all print and digital publicity / social media distributed for the meeting

My signature below signifies that the information provided herein is accurate, that I have been authorized by the organization listed above to submit this application on their behalf, and that this educational activity is in compliance with all of the ISHLT Policies regarding Endorsement.

Name: ______

Signature: ______

Date: ______