CME/CPD Commercial Independence Disclosure Form

    This form should be completed by Organizers, Planners, Speakers, Presenters, Lecturers, Chairpersons, Moderators, Trainers, Authors and others who are having a role during a CME/CPD Activity.

    Speakers/Presenters/Lecturers/Chairpersons/Moderators/Trainers/Authors Information:


    Name*


    Degree*


    Email*


    Phone Number*

    *Common types of financial relationships include full-time or part-time employment, consulting, speaker’s bureau, grant/research support, stock ownership, honoraria, etc.


    Is the financial relationships related to content of the CME/CPD activity?*

    Please list all aspects of this activity that you planned or coordinated:*