Additional Author COI Submission Form

Submission deadline: Extended to July 28, 2019 (midnight EDT)

NOTE: In case of multiple authors, COI information must be completed for each author listed on the poster.

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

(Conflict of Interest information is required for each author



Disclosure:  Author Name, Contact and Disclosure:

First Name:
Last Name:
*Degree/Title:
(List most current, highest degree first, then licensure and certification credentials)
*Organization / Affiliation:
*Address:
*City:
*St:
*Zip:

  *List at least one phone number

WorkPhone:
CellPhone:
HomePhone:


I have received Sponsorship from:

I am employed by industry:

I have received an honorarium/fee from a company associated with this poster:

Any other potential conflict:

*In lieu of signature, by checking this box I certify the information provided herein is true and accurate:

 


  

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