Conflict of Interest Disclosure Form DISCLOSURE

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Conflict of interest disclosure

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DISCLOSURE SLIDE i. EITHER please state your disclosures including, but not limited to, - Personal financial interests, incl. honoraria you have received.

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FINANCIAL DISCLOSURES

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Conflict of Interest Disclosure Form

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Conflict of Interest Disclosure Form DISCLOSURE Name: Affiliation: DISCLOSURE I have no potential conflict of interest to report* I have the following potential conflict(s) of interest to report* * Please delete as appropriate. Type of affiliation / financial interest Name of commercial company Receipt of grants/research supports: Receipt of honoraria or consultation fees: Participation in a company sponsored speaker’s bureau: Stock shareholder: Spouse/partner: Other support (please specify):

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