Submit a request – CPT Renewals

Your email address

Subject(optional)

Licensee Name

Name of the legal entity under this contract

Contract ID of CPT® Distribution License Agreement

Original effective date of CPT® Distribution License Agreement

Original Expiration date of CPT® Distribution License Agreement

Business Address:

City

State:

Zip Code:

Please verify your Licensed Products:

Please verify the AMA Licensed Content:

Do the affiliates on your agreement match any current affiliates?

If you have affiliates, they are identified in Schedule A3 of the contract

Please list any current affiliates(optional)

Type "none" if you no longer have any affiliates to list

Attestation to accuracy of current CPT® Distribution License Agreement

Please attest to the accuracy of the information provided above.

Has anything in your business changed?(optional)

For example, your company acquired company X.

Comments or Questions

This is a required field. Please enter any additional comments or details that are necessary to complete this request.

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