WAFP Faculty Information

Name *

First

Last

Email *

Phone *

How to reach you the day of the session

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Official Topic Title *

Please list the learning objectives for this session: *

Please provide a short bio: (2-3 sentences) *

Conflict of Interest

In 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. *

Yes
No

If yes, please indicate the nature of your affiliation:

Specify Other

Discussion or Products

Will your program or presentation include a discussion of products which you have had a role in developing or marketing? *

Yes
No

Will your program or presentation include a discussion of off-label use of commercial products or unapproved investigational use of any product? *

Yes
No

Please 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) *

First

Last

Signature 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.

Conflict of Interest

Discussion or Products

Please sign below:

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