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As a member of the Planning Committee for the 72nd Annual Region Three Meeting, thank you for vising this page to complete your Planning Committee Disclosure Form.  

To complete this form

1) Type in your first name, last name, and email address 
2) Select the appropriate checkbox for the Disclosures Form and if appropriate, enter any disclosures which may exist
3) Use your finger or mouse to enter your digital signature
4) Select "Submit"

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  • 1) COMMITTEE MEMBER CONTACT INFO




  • 2) FINANCIAL DISCLOSURES

  • If applicable, please check which type of disclosure(s) you need to make and then list the relevant names of the companies/organizations.






  •  

    If your web browser autofills your name in the text boxes below, please remove your name.

  • 3) ELECTRONIC SIGNATURE

  • 4) SUBMIT

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Phone : 717-763-7665
Fax : 717-761-4091
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The William L. Goldfarb Foundation 757 Poplar Church Road
Camp Hill, PA 17011