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Renew Your Existing Account

This form is for EXISTING accounts only.
If this is a new account, please click on the Sign Up tab.

- US Programs
- $200 Administrative fee per program
- $1000 per physician with a $2500 maximum at an program for 3 or more physicians
- International Programs
- $200 Administrative fee per program
- $1000 per year per site
Name*
First Last
Are you based in the United States?*
- Yes
- No
Phone*
Phone (International)*
Email Address*
Name of Program or Primary Institution*
Name of CESQIP Physician Champion at your site?*
First Last
Physician Champion phone*
Physician Champion phone (Int'l)*
Physician Champion email*
Name of CESQIP Administrative Champion at your site?*
First Last
Administrative Champion phone*
Admin. Champion phone (Int'l)*
Administrative Champion email*
In how many new facilities (if any) do your program’s surgeons perform endocrine surgery procedures?*
Please list the name(s) of each new facility/hospital in your program*
Does this facility have a Data Use Agreement with CESQIP?*
Site Name*
Does this facility have a Data Use Agreement with CESQIP?*
Site Name*
Does this facility have a Data Use Agreement with CESQIP?*
Site Name*
Does this facility have a Data Use Agreement with CESQIP?*
Site Name*
Does this facility have a Data Use Agreement with CESQIP?*
Site Name*
Does this facility have a Data Use Agreement with CESQIP?*
Site Name*
Does this facility have a Data Use Agreement with CESQIP?*
Site Name*
Does this facility have a Data Use Agreement with CESQIP?*
Site Name*
Does this facility have a Data Use Agreement with CESQIP?*
Please list all CESQIP participants at your program*
Participant Name Email Address

Please include surgeons, administrators, fellows, etc.
To add another participant, click the (+) button.
Please be accurate, as non-listed accounts will be de-activated.
I would like to pay by*
- Online by credit card (convenience fee applies)
- Mail a check
- I am a member of Latin American CESQIP (no payment due)
Total Number of Physicians In Program*
Please list the total number of physicians in your program, across all sites.
Total Number of Physicians In Program*
Please list the total number of physicians in your program, across all sites.
Total Number of Physicians In Program*
Please list the total number of physicians in your program, across all sites.
Annual Administrative Fee*
Price: $200.00
DUA Fee:
Subtotal:
Subtotal:
Credit Card Convenience Fee*
Price: $0.00
Credit Card Convenience Fee*
Price: $0.00
Total (including credit card convenience fee)
$0.00
Total
$0.00
Credit Card*

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Card Number Expiration Date Security Code Cardholder Name