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COI - additional authors

COI - additional authors


Submission Instructions

Submission deadline: June 13th, 2021 (midnight EDT)
NOTE: It is recommended to print the blank submission form to review prior to completing. Once you have started the application it cannot be saved. If this page is closed without submission, all information entered will be deleted.
Print a blank copy of this form now.

Fields with * are required. Complete all other fields as appropriate or enter "N/A" if not applicable.

*Person submitting this form:



*Additional Author Name, Contact and Disclosure


(List most current, highest degree first, then licensure and certification credentials)

Conflict of Interest Disclosure (Additional Author)









Note: If the form does not submit, go up the page to make sure you've completed all required fields.

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