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Acceptance and Disclosure Statement
In the disclosure section, please enter all interests (including employment, consulting, or other financial interests) held by committee member or member’s family that could constitute a conflict from January 2022 to present. Once completed, please select 'submit' at bottom of page.
Last Name
*
First Name
*
Click here to View the COI Policy
I acknowledge that I have received a copy of the International Society for CNS Clinical Trials conflicts of interest policy; that I have read, understand and agree to comply with the policy.
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Yes
I understand the International Society for CNS Clinical Trials is a charitable organization and in order to maintain its federal tax exemption, it must engage primarily in activities which accomplish one or more of its tax-exempt purposes.
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Yes
Please select one. If you have more than 5 companies to report, please choose option 3 and email to Executive Director.
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I have nothing to report.
I have completed the below online disclosures.
I am emailing disclosures to Executive Director.
Company 1
Type of Support Company 1 (e.g., employee, grant, consulting fees)
Equity/Stockholder - Company 1
Yes
No
Company 2
Type of Support Company 2 (e.g., employee, grant, consulting fees)
Equity/Stockholder Company 2
Yes
No
Company 3
Type of Support Company 3 (e.g., employee, grant, consulting fees)
Equity/Stockholder Company 3
Yes
No
Company 4
Type of Support Company 4 (e.g., employee, grant, consulting fees)
Equity/Stockholder Company 4
Yes
No
Company 5
Type of Support Company 5 (e.g., employee, grant, consulting fees)
Equity/Stockholder Company 5
Yes
No
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