Upload Your Faculty Contract Here: Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone *How to reach you the day of the sessionAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeOfficial Topic Title *Please list the learning objectives for this session: *Please provide a short bio: (2-3 sentences) *Conflict of InterestIn the past 12 months, did you or an immediate family member (parent, sibling, spouse, partner, or child) have a financial relationship or affiliation with any corporate organization or commercial interest*? *A commercial interest is considered any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. *YesNoIf yes, please indicate the nature of your affiliation:Grant/Research SupportConsultantSpeaker's BureauOwnershipStock/Bond Holdings (excluding mutual funds)EmploymentOtherSpecify OtherDiscussion or ProductsWill your program or presentation include a discussion of products which you have had a role in developing or marketing? *YesNoWill your program or presentation include a discussion of off-label use of commercial products or unapproved investigational use of any product? *YesNoPlease sign below:I have read the WAFP policy on disclosure of interests. If I have indicated a financial relationship or interest, I understand that this information will be reviewed to determine whether this relationship precludes my participation, and I may be asked to provide additional information. I understand that failure or refusal to disclose, false disclosure, or inability to resolve conflicts of interest will disqualify me from participating in this activity.Electronic Signature (please sign by typing your full name) *FirstLastSignature Date *Presentation Uploads Click or drag files to this area to upload. You can upload up to 5 files. Please upload your presentations. A final slide deck will be required for our CME application.Biography & Photo Click or drag files to this area to upload. You can upload up to 5 files. Please provide a short bio and head shot.MessageSubmit
