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COI Disclosure Form
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COI Disclosure Form
Conflict of Interest Submission
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Last
Date
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Are you a voting Governing Council member?
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Are you a Committee or Task Force member?
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If you are a Committee or Task Force member, please indicate which ones below:
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I affirm the following:
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I have read and understand the WSS Conflict of Interest Policy.
I agree to comply with the Conflict of Interest Policy.
I understand that WSS is a non-profit organization and in order to maintain its federal tax exemption it must engage primarily in activities which accomplish one or more tax-exempt purposes.
Do you have a current financial interest (current or potential) as defined in the Conflict of Interest (COI) Policy with WSS?
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Please disclose the COI:
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In the past, have you had a financial interest as defined in the Conflict of Interest Policy with WSS?
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Please disclose the COI, including approximate timeframe:
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Are you a voting member of a Board of Directors or governing body of any medical or professional society?
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Please disclose the associations you have a voting interest within:
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Confirmation
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The information in this Conflict of Interest Disclosure Form is accurate and complete.