2021 FDS Speaker Bio & Disclosure Statement

  • Biosketch

    Please enter information here exactly as you would like it listed in the meeting program and syllabus.
  • JPEG or PNG. Max size 8 MB.
    Accepted file types: jpg, png, Max. file size: 10 MB.
  • Speaker Disclosure Statement

    If you are presenting more than once, you only need to complete one disclosure.
  • Speaker Disclosure Statement

    The Medical Educational Council of Pensacola (MECOP) requires that all speakers, faculty members and planning committee members complete a Disclosure Statement so that relevant relationships with commercial interests are disclosed to the provider.  All relevant relationships of the speaker/committee member and their spouse/partner must be listed below.

    Please note that MECOP defines “relevant” as any relationship/dollar amount in the past 12 months.  A commercial interest is any entity that produces, markets, re-sells, or distributes health care goods or services consumed by, or used on, patients. 

    Each speaker is required to complete this form.

    Conference Name: 2021 Virtual APGO Martin L. Stone, MD, Faculty Development Seminar
    Date: January 10-12, 2021
  • Do you have any potential conflicts of interest to disclose? If so, please list them here including Company Name, Relationship and whether it is self/spouse/partner. If you have nothing to disclose, type NONE in the text box.
  • By typing your name here, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this disclosure statement.
  • MECOP does not imply that such relationships will prevent the speaker/committee member from making an unbiased presentation/decision. However, it is imperative that such relationships be identified so that MECOP can determine work to resolve any conflict(s) of interest, should one arise.