Conflict of Interest Event Participation Form Conflict of Interest Event Participation Form First Name*Last Name*Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Primary Phone*Cell Phone*FaxEmail* CME Conflict of Interest Form It is policy of the National Arab American Medical Association to insure balance, independence, objectivity, and scientific rigor in all its individually sponsored or jointly sponsored programs. All individuals who have influence on the scientific content or presentation of scientific material in any NAAMA-sponsored programs are expected to disclose to the program audience any real or apparent conflict(s) of interest that may have a direct bearing on the subject matter of the continuing medical education program. This pertains to relationships with pharmaceutical companies, biomedical device manufacturers, or other commercial entities that resell, distribute, and/or market healthcare products used on or by patients and/or whose products or services are related to the subject matter of the presentation topic. This also pertains to relationships your spouse or partner has with pharmaceutical companies, biomedical device manufacturers, or other corporations that resell, distribute, and/or market healthcare products used on or by patients and/or whose products or services are related to the subject matter of the presentation topic. Financial relationships are not limited to "significant" relationships. The intent of this policy is not to prevent an individual with a potential conflict of interest from involvement in a NAAMA-sponsored program. It is merely intended that any potential conflict should be identified openly so that the listeners may form their own judgments about the program with the full disclosure of the facts. Speakers and others are free to discuss off-label uses for drugs, products or modalities, provided the audience is informed of this off-label use. It remains for the audience to determine whether the outside interests may reflect a possible bias in either the exposition or the conclusions presented.I am a member of the Scientific Committee CME Activity Faculty Event Planning Committee Session Moderator or Chair Other Check all that applyOtherConflict of Interest Disclosure A. Nothing to Disclose: I have no actual or potential conflict of interest in relation to this program or any presentation topic or speaker that will preset at this CME event. B. I Have Affiliations to Disclose I have financial interests, arrangements or affiliations with organizations resulting in perceived real or apparent conflict of interest in selecting topics or speakers for this activity. Conflict of Interest Disclosure*A. I Have Nothing to DiscloseB. I Have Affiliations to DiscloseDisclosure Details* Grant/Research Support Consultant Speakers' Bureau Major Stock Shareholder Employee of ACCME-Defined Commercial Entity Other / Additional Check all that applyGrant/Research Support Details*Consultant Details*Speakers’ Bureau Details*Major Stock Shareholder Details*Employee of ACCME-Defined Commercial Entity Details*Other / Additional*Conflict of Interest Disclosure*A. My Spouse or Partner Has Nothing to DiscloseB. My Spouse or Partner Has Affiliations to DiscloseDisclosure Details* Grant/Research Support Consultant Speakers' Bureau Major Stock Shareholder Employee of ACCME-Defined Commercial Entity Other / Additional Check all that applyGrant/Research Support Details*Consultant Details*Speakers’ Bureau Details*Major Stock Shareholder Details*Employee of ACCME-Defined Commercial Entity Details*Other / Additional*All information provided above is accurate to the best of my knowledge. This electronic form qualifies as an electronic signature on my behalf.* I Agree NameThis field is for validation purposes and should be left unchanged.