Faculty Disclosure Form

AGES Society wishes to ensure independence, objectivity, scientific rigour and a fair balance of representation, in all its individual or jointly sponsored educational activities and on all committees and boards. All speakers at educational events and all authors presenting at any AGES’ meetings are required to make a declaration.

Disclosure forms must be submitted prior to each event at which the below signed is presenting at. All financial relationships at any time in the previous 12 months and any that will commence within 3 months of submission of this form must be disclosed.

Faculty Disclosure Form

Name(Required)

First Last

Disclosure(Required)

Declaration of financial relationships or commercial affiliations(Required)

Please use the following list to declare your existing or known financial relationships or commercial affiliations. Check the in the appropriate box and indicate the name of the company in the box provided.

Equity interests (or entitlement to same) of stocks, stock options, royalties, etc, including income from patents or copyrights.

Service as a director or employment by a commercial organisation, whether or not remuneration is provided for such service

Sole ownership, partnership or principal of a commercial enterprise

Ownership of patent(s)

Receipt of royalties

Consultant to company including positions on medical or scientific advisory boards

Honoraria for speaking at company sponsored meetings or events

Participation in clinical trials

Support in the form of fellowships, travel grants, gifts, in-kind donations, etc.

Research grants, partial or full salary support from a commercial organisation for self or employees for whom you are managerially responsible (i.e laboratory technical/research fellow for whom you are managerially responsible)

Any other type of financial or other relationship

Please indicate the name of the company and/or description of financial relationships or commercial affiliations below(Required)

Signature(Required)

Date(Required)

DD slash MM slash YYYY

Confirmation Email(Required)

You will receive an automated confirmation email once this form has been submitted.

YRD Event Management
PO Box 717 Indooroopilly
QLD 4068 AUSTRALIA

P: +61 7 3368 2422
F: +61 7 3368 2433
ABN: 33 075 573 367

In the spirit of reconciliation, AGES acknowledges the Traditional Custodians of the country throughout Australia and their connections to land, sea, and community. AGES pays respect to their Elders past and present and extend that respect to all Aboriginal & Torres Strait Islander peoples today.