Below you will find two initials statements, one of which will apply to you in connection with serving as a faculty member for the 25th Annual Scientific Meeting.

If you do not have a financial interest or other relationship with a commercial company related directly or indirectly with the 25th Annual Scientific Meeting, select "agree" for question 1, enter your full name and the date where indicated, and select "done." If you mark question 1, DO NOT select "yes" under subsequent questions.

If question 1 is not applicable, please read each of the following statements and select the statement(s) which apply to you.  If you have any financial interest or relationship to disclose, select "yes" and include the name of the commercial company in the box.

Your disclosure will be listed in the Final Program/Course Syllabus.

The Academy does not view the existence of these interests or commitments as necessarily implying bias or decreasing the value of your participation in Academy activities.

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* 1. I (or a member of my immediate family) do not have a financial interest or other relationship with a commercial company or institution. If you agree, skip all remaining questions, scroll down, and enter your name and date.

If you have any financial interest or other relationships please be sure to check all that apply below and include the company name(s).

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* 2. Do you or a member of your immediate family receive royalties for any pharmaceutical, biomaterial or orthopaedic product or device?

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* 3. Within the past twelve months, have you or a member of your immediate family served on the speakers bureau or have you been paid an honorarium to present by any pharmaceutical, biomaterial or orthopaedic product or device company?

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* 4. Are you or a member of your immediate family a paid employee for any pharmaceutical, biomaterial or orthopaedic device or equipment company, or supplier? (3A)

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* 5. Are you or a member of your immediate family a paid consultant for any pharmaceutical, biomaterial or orthopaedic device or equipment company, or supplier? (3B)

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* 6. Are you or a member of your immediate family a unpaid consultant for any pharmaceutical, biomaterial or orthopaedic device or equipment company, or supplier? (3C)

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* 7. Do you or a member of your immediate family own stock or stock options in any pharmaceutical, biomaterial or orthopaedic device or equipment company, or supplier (excluding mutual funds)?

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* 8. Do you or a member of your immediate family receive research or institutional support as a principal investigator from any pharmaceutical, biomaterial or orthopaedic device or equipment company, or supplier?

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* 9. Do you or a member of your immediate family receive any other financial/material support from any pharmaceutical, biomaterial or orthopaedic device and equipment company or supplier?

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* 10. Do you or a member of your immediate family receive any royalties, financial/material support from any medical and/or orthopaedic publishers?

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* 11. Enter your full legal name including credentials. By typing your name, you attest that all information above is correct.

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* 12. Enter today's date in mm/dd/year format. Example: 04/14/2014

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