Call for Abstracts Disclosure Form

Call for Abstracts Author Disclosure Form

Fullname

First Name
Last Name
Title
Email
Check the box below to signal that you do/do not have a disclosure to be made.
I DO have an actual or potential conflict of interest in relation to the abstract.
I do NOT have an actual or potential conflict of interest in relation to the abstract.
Checkbox
Major Stock/Share Holder
Speakers' Bureau
Consultant
Grant/Research Support
Other Financial/Material Support
Name of commercial interest(s) you own stock in or are a shareholder of:
Name of commercial interest(s) whose Speakers' Bureau you are on:
Name of commercial interest(s) who you consult for:
Name of commercial interest(s) who provide you grant/research support:
Name of commercial interest(s) who provide Financial/Material Support to you:

The William L. Goldfarb Foundation 757 Poplar Church Road

Camp Hill, PA 17011