Conflict of Interest Form

* 1. Please fill out the form below:

Name:

Address:

Address 2:

City/Town:

State:

ZIP:

Email Address:

Phone Number:

* 2. I acknowledge that I have received a copy of the Conflict of Interest Policy Statement (“Policy”) of the Iowa Academy of Family Physicians (IAFP) and that I have read, understand and agree to comply with the Policy.

Yes

* 3. Please check all appropriate IAFP activities:

IAFP Board of Directors

IAFP Committee Member

IAFP Staff

Other (please specify)

* 4. Do you have any conflicts of interest?

I have no real or apparent conflict of interest.

Yes, I will disclose below.

* 5. I hereby declare and certify the following real or apparent conflict(s) of interest.
(Please list the company, what was received and what role it was for)

* 6. Please type your name here; we will treat this as your signature:

* 7. Date:

Date

Thank you for completing the IAFP's Conflict of Interest form. This disclosure is valid for one year, but should you have relevant changes within the year, please notify IAFP staff. You will be contacted by a IAFP staff member if there are questions pertaining to your disclosure.