International Symposium on Prostate, Androgens and Menís Sexual Health

InterContinental Hotel Berlin - 21 to 23 June 2013

Conflict of Interest Disclosure Form

Please carefully ready and complete the disclosure form below.

Title of CME Activity: International Symposium on Prostate, Androgens and Men's Sexual Health
Activity Number/Date: 21 to 23 June 2013
Location of Activity: Berlin, Germany
1. CME Presenter/Author Name:

First Name

Last Name


2. Disclosing as:

1. Presenter (invited presentation or abstract presentation)       
2. Author (author or co-author of an accepted abstract)       
3. Presenter and Author (any combination of 1. and 2.)       
4. Other (if you do not present and are not an author of an abstract)

Presenters: please complete questions 3+4+5, sign and date below.
Authors: please complete question 4A, sign and date below.

(See glossary of terms for guidance)

CME Presenters:
Questions 3+4+5
By signing this document, I agree to the following elements as expected of individuals involved in the planning and implementation of educational activities certified by the University of Oklahoma College of Medicine, Office of Continuing Medical Education.
CME Authors:
Question 4A
Presenters must answer questions 3+4+5. Do not forget question 4B. Authors must answer Question 4A.

3. All CME speakers must read, agree, and check the all following statements. I will:

A. I or my spouse/partner presently (within the past 12 months) has relevant financial relationships with a commercial interest(s) as identified below:
[Please indicate the full name of the commercial interest(s)/organization(s) next to the best description of the relationship(s).]
B. Will your presentation(s) include discussion of any products or services from the above listed commercial interest(s)?
I will make clinical recommendations in this/these presentation(s).
By selecting "I Agree" I represent and acknowledge that:
  1. I have read, understood, and consented to electronic delivery of, the disclosures above.
  2. I intend the act of selecting "I Agree" to be my legal signature to this agreement.
Email address

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Date (Y-M-D)