1. List the names of any commercial entities producing health care goods or services with which you or your spouse/partner have, or have had, a relevant financial relationship within the past 12 months.  For this purpose, we consider your spouse's or partner's relevant financial relationships to be yours.  (Non-profit or government organizations and non-healthcare related companies are exempt.)
  2. Describe what you or your spouse/partner received, such as salary, honorarium, consulting fees, royalties, grants, intellectual property, ownership interest, stock (excluding diversified mutual funds), etc..
  3. Describe your role with the commercial supporters and/or interests, such as speaker, researcher, employment, investor, management, independent contractor, teacher, membership on advisory or review committees, board member, consultant, etc.

1.  Commercial Supporter and/or Interest

(Name of Company)

2.  What I received

i.e., stocks, honorarium, etc.

3.  My role

i.e., advisor, stockholder, speaker

By adding your initials below, you are stating "I do not have any relevant financial relationships with any commercial interests".

By typing your name below, you agree that you are signing this form electronically, and that your electronic signature is the legal equivalent of your manual signature. You also acknowledge that you have read and agree with the CME activity requirements.

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