2024 UMEC Bio and Disclosure Form

Please complete this information exactly as you would like it to appear in meeting materials.
First Name*
Middle Name or Initial (optional)
Last Name*
Degrees (MD, DO, etc)*
Institution*
Academic Position*
Email*
Biosketch*
Headshot
Max. file size: 50 MB.
2024 Speaker Disclosure Statement
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 a commercial interest(s). Please specify relationships below:
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.

2024 Speaker Disclosure Statement