Conflict of Interest Form Question Title * 1. Please fill out the form below: Name: Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Email Address: Phone Number: Question Title * 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 No Question Title * 3. Please check all appropriate IAFP activities: IAFP Board of Directors IAFP Committee Member IAFP Staff Other (please specify) Question Title * 4. Do you have any conflicts of interest? I have no real or apparent conflict of interest. Yes, I will disclose below. Question Title * 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) Question Title * 6. Please type your name here; we will treat this as your signature: Question Title * 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. Done