Speaker and Co-Author Financial Disclosure Form

 Only one disclosure form is required per Speaker/CoAuthor.



Society of Military Orthopaedic Surgeons
110 West Road, Suite 227, Towson, MD 21204
866-494-1778

Mandatory Financial Disclosure Statement

Below you will find a statement that will apply to you in connection with your participation in the Society of Military Orthopaedic Surgeon's 51st Annual Meeting, December 14-19, 2009.

If you have a financial interest or other relationship with a commercial company, related directly or indirectly with SOMOS's 51st Annual Meeting, answer "Yes" and provide the name of the company. If not, indicate you have nothing to disclose. Your disclosure will be listed in the Final Program/Course Syllabus.

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

1. I (or a member of my immediate family) have a financial interest or other relationship with a commercial company related directly or indirectly to the SOMOS 51st Annual Meeting. *
Yes
I have nothing to disclose.



Please list below the name of the company or companies that apply to each statement.
a. Research or institutional support has been received from:
b. Miscellaneous nonincome support (e.g., equipment or services), commercially derived honoraria, or other nonresearch related funding (e.g., paid travel) has been received from:
c. Royalties have been received from:
d. Stock or stock options held in:
e. Consultant or employee of:


 
Full Name *


 
I am *
a Speaker
a Co-Author


 
Speaker Author Name


 
Presentation Title *




(c) 2010 Society of Military Orthopaedic Surgeons
110 West Road, Suite 227
Towson, MD 21204
T: 866-494-1778
F: 410-494-0515
E-mail