Conflict of Interest Disclosure Form

On the following pages, please disclose all financial relationships that you have had in the past 24 months with ineligible companies.

For each financial relationship, enter the name of the ineligible company and the nature of the financial relationship(s). There is no minimum financial threshold; we ask that you disclose all financial relationships, regardless of the amount, with ineligible companies. You should disclose all financial relationships regardless of the potential relevance of each relationship to the writing group topic.

Please also disclose any other publications related role you currently hold with related societies.

Question Title

* First Name

Question Title

* Please list the writing group for which you are applying:

Question Title

* Please list any publications related volunteer roles (i.e., writing group member, publications committee member, journal editorial board, etc.) with related societies (i.e. IUGA, SGS, AAGL, SGO, SMFM, etc.) that you would hold concurrently while serving as a member of the AUGS writing group. Please list both the position held and the organization. (I.e., Writing Group Member, AUGS.) If none, please type "N/A" in the first answer row.

Question Title

* In the past 24 month have you had any financial relationships with any ineligible companies?

T