should not have a financial interest, direct or indirect, in the outcome of an issue with which he/she is involved. In addition, an ACFAS representative should not be employed by or accept gifts, favors, discounts, or anything else of substantial value from anyone with an interest or stake in the outcome of an issue with which he/she is involved. ACFAS members, staff, or related parties are subject to removal from elective or appointed office or termination of employment if they violate this policy. Please provide the information requested below (attach additional paper if necessary). REFERS TO YOU OR “YOU” A FAMILY MEMBER (spouse or domestic partner, parent, children or step-children): Are you receiving any compensation from a for-profit or non-profit organization for your participation in any ACFAS activity(ies)? Yes No If yes: Company(ies) name Amount(s) $ Do you serve in any official capacity, either elected or appointed, for any other medical or podiatric organization (non-profit or for-profit)? Yes No If yes, please identify position(s)and organizations(s) Are you conducting sponsored research activities? Yes No If yes, please disclose the sponsors: Are you a consultant or speaker for a commercial company whether on a formal or informal Yes No If yes, please disclose the company(ies): Do you have any investments which might reasonably be considered a conflict of interest? Yes No If yes, please disclose the investments: Are there any other relationships between you and a commercial company whether oral or written, that should be disclosed pursuant to the rules and examples outlined in the ACFAS Conflict of Interest policy? Yes No If yes, please disclose: I understand and to the attached conflict of interest policy and disclosure form. I hereby certify that the above is accurate. If these facts change during my period of service to ACFAS, I will immediately amend this statement and file the amended statement with ACFAS. Failure to disclose, recuse, or comply with these policies would be subject to review by the Conflicts of Interest Subcommittee and possible dismissal from the position. _______________ Signature Date Print name LEGIBLY
should not have a financial interest, direct or indirect, in the outcome of an issue with which he/she is involved. In addition, an ACFAS representative should not be employed by or accept gifts, favors, discounts, or anything else of substantial value from anyone with an interest or stake in the outcome of an issue with which he/she is involved. ACFAS members, staff, or related parties are subject to removal from elective or appointed office or termination of employment if they violate this policy. Please provide the information requested below (attach additional paper if necessary). “YOU” REFERS TO YOU OR A FAMILY MEMBER (spouse or domestic partner, parent, children or step-children): Are you receiving any compensation from a for-profit or non-profit organization for your participation in any ACFAS activity(ies)? Yes No If yes: Company(ies) name Amount(s) $ Do you serve in any official capacity, either elected or appointed, for any other medical or podiatric organization (non-profit or for-profit)? Yes No If yes, please identify position(s)and organizations(s) Are you conducting sponsored research activities? Yes No If yes, please disclose the sponsors: Are you a consultant or speaker for a commercial company whether on a formal or informal Yes No If yes, please disclose the company(ies): Do you have any investments which might reasonably be considered a conflict of interest? Yes No If yes, please disclose the investments: Are there any other relationships between you and a commercial company whether oral or written, that should be disclosed pursuant to the rules and examples outlined in the ACFAS Conflict of Interest policy? Yes No If yes, please disclose: I understand and to the attached conflict of interest policy and disclosure form. I hereby certify that the above is accurate. If these facts change during my period of service to ACFAS, I will immediately amend this statement and file the amended statement with ACFAS. Failure to disclose, recuse, or comply with these policies would be subject to review by the Conflicts of Interest Subcommittee and possible dismissal from the position. _______________ Signature Print name LEGIBLY Date
2012-13NominationApplication.docx