2020-2021

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* Please fill in the information below:

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* Please list your positions of employment, including the name of the institution/organization, title of your position, and brief description.
If none, please enter N/A.

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* Please list any other Board positions you hold, including a brief description of the nature and purpose of the organization.
If none, please enter N/A.

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* Please list any relationships in which you hold a position of responsibility or a substantial financial interest (other than a 1% interest in a publicly traded company) from which SAEM obtains or may obtain substantial amounts of goods or services, or which provides services that substantially compete with SAEM.
If none, please enter N/A.

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* Please list any substantial financial interests or positions of responsibility in entities providing goods or services in support of the practice of emergency medicine (e.g., physician practice management company, billing company, physician placement company, book publisher, medical supply company, malpractice insurance company), other than owning less than a 1% interest in a publicly traded company.
If none, please enter N/A.

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* Please list any other interest you believe may create a conflict with the fiduciary duty to the membership of SAEM or that may create the appearance of a conflict of interest.
If none, please enter N/A.

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* I understand that typing my name below constitutes a legal signature confirming that the information I have entered above is correct to the best of my knowledge.

I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.

Please click "Done" to submit your Conflict of Interest Disclosure Form.

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