APGO FDS 2022 Plenary Speaker Information

Please enter all information on this form as you would like it to appear in meeting materials. The disclosure information at the bottom is required of all speakers. Thank you!

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:*
Email address:*
Biosketch:
Headshot upload:*
Please attach a headshot for use in our online meeting materials. (.jpeg preferred)
Max. file size: 50 MB.
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: 2021 APGO Martin L. Stone, MD, Faculty Development Seminar
Date: January 10-12, 2021
Location: Online
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.

APGO FDS 2022 Plenary Speaker Information

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Speaker Disclosure Statement