I intend to
reference unlabeled/unapproved uses of drugs or products in my
presentation (specify drug(s) or product(s) by name for which the
unlabeled use will be discussed.
I have read the Disclosure Requirements and to the best
of my knowledge, the information provided on this form is true and
correct and represents all items for disclosure. I understand that
failure to comply with the disclosure policy, when known and deliberate,
may result in disqualification for two years in similar educational or
related activities. I agree to promptly notify the program
directors is any of this information changes.