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COI Disclosure Form

> COI Disclosure Form

Conflict of Interest Submission

Name(Required)

First Last

Date(Required)

MM slash DD slash YYYY

Are you a voting Governing Council member?(Required)

Yes

No

Are you a Committee or Task Force member?(Required)

Yes

No

If you are a Committee or Task Force member, please indicate which ones below:(Required)

I affirm the following:(Required)

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?(Required)

Yes

No

Please disclose the COI:(Required)

In the past, have you had a financial interest as defined in the Conflict of Interest Policy with WSS?(Required)

Yes

No

Please disclose the COI, including approximate timeframe:(Required)

Are you a voting member of a Board of Directors or governing body of any medical or professional society?(Required)

Yes

No

Please disclose the associations you have a voting interest within:(Required)

Confirmation(Required)

The information in this Conflict of Interest Disclosure Form is accurate and complete.

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