1. Disclosure Statement of Financial Interest I, (insert name),I, (insert name), DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation. DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.

2. Disclosure Statement of Financial Interest I, (insert name), DO have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation, they are:I, (insert name), DO have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation, they are: Affiliation/Financial Interest:Name of Organization (s): Grant/Research Support: Grant/Research Support: Consultant: Consultant: Speaker's Bureau: Speaker's Bureau: Major Stock/Shareholder : Major Stock/Shareholder : (excluding mutual funds) Advisory Board: Advisory Board:

3. Disclosure Statement of Unapproved/Investigative Use I, ( insert name), DO/DO NOT anticipate discussing the unapproved/investigative use of a commercial product/device during this activity or presentation.