The Dental Forum of Milwaukee

Conflict of Interest Declaration

Having an interest in or affiliation with any corporate organization does not prevent a speaker from making a presentation, but the relationship must be made known in advance to the audience.

PROGRAM TITLE:

NAME:

I do not have any financial arrangements or affiliations with any corporate organizations and/or products mentioned in or providing support for this Continuing Dental Education program.

Signature Date
OR

I have a financial interest/arrangement with one or more of the corporate organizations/products mentioned in or offering financial support for this Continuing Dental Education program.

Affiliation/Financial Interest Name/Corporate Organization(s)

Grant/Research Support ____________________

Consultant ____________________

Speaker's Bureau _________________

Stock Shareholder ___________________

Other Financial/Material Support ___________________

Signature                        Date

Your cooperation in complying with these guidelines is appreciated. This form should be returned with a course synopsis and abbreviated (1 5 pages) curriculum vitae to:

The Dental Forum of Milwaukee

c/o: ______________________________________, Current Program Chair Name & Address
 

 

 

 

Thank you for your support.