APGO FDS 2023 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!

  • Type N/A if not applicable.
  • Cell phone for on-site use.
  • Please attach a headshot for use in our online meeting materials. (.jpeg preferred)
    Max. file size: 50 MB.
  • 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: 2023 APGO Martin L. Stone, MD, Faculty Development Seminar
    Date: January 7-10-2023
    Location: Westin Kierland Resort nd Spa, Scottsdale, AZ
  • 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.