2025 FDS Plenary Speaker Information

First Name:*
Middle Name (optional):
Last name:*
Suffix(es):*
Type N/A if not applicable.
Academic Rank and Title*
Institution*
Street Address:*
City, State, Zip Code:*
Phone number (cell phone for on-site use only):*
Email address:*
Biosketch:*
Headshot upload:*
Please attach a headshot for use in our online meeting materials. (.jpeg preferred)
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Plenary Title:*
Plenary Précis:*
Plenary Key Takeaway:*
Workshop Title (if applicable):
Workshop Précis (if applicable):
Workshop Key Takeaway
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: 2025 APGO Martin L. Stone, MD, Faculty Development Seminar
Date: January 11-14, 2025
Location: Marriott Resort Waikiki Beach, Honolulu, HI
Commercial Interests:*
- I DO NOT have a relevant relationship with any commercial interest(s), and neither does my spouse/partner.
- I DO have a relevant relationship with any commercial interest(s), and neither does my spouse/partner.
Potential Conflicts of Interest (type NONE if no conflicts)*
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.
Discussion*
- I WILL NOT be discussing off label/investigational use of a commercial product or device.
- I WILL be discussing off label/investigational use of a commercial product or device.
Signature*
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.

2025 FDS Plenary Speaker Information

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Speaker Disclosure Statement