College of Medicine
(PLEASE SIGN A OR B, WHICHEVER IS APPLICABLE)
CME Activity: _______________________________________________
A. I, the undersigned, declare that I do not have a financial interest or other relationship with any manufacturer(s) of any commercial product(s)
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__________________________ (Signature) |
__________________________ (Date) |
B.
I, the undersigned, declare that I have a financial interest or other
relationship with a manufacturer(s) of a commercial product(s). Thsi financial
interest or relationship is specified below.
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Company: ___________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ |
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Company: ___________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ |
| __________________________ (Print Name) |
__________________________ (Signature) |
__________________________ (Date) |
This form must be returned to the address shown below. Failure to disclose or false disclosure will require UIC to identify a replacement for you.
UNIVERSITY
OF ILLINOIS
OFFICE OF CME, Room 115A CMW
1853 West Polk Street, M/C 784
Chicago, IL 66012