Financial Disclosure Form

Providers must resolve conflict of interest prior to the educational activity.

Please read the UAFP Financial Disclosure Policy before completing the following portion of this form.

Disclosure of all financial relationships with ineligible companies within the 24 months of the completion date of this form is required. For a list of ineligible organizations, click here.

The intent of this policy is not to prevent individuals from participating, but rather to identify and mitigate any relevant financial relationships. Should mitigation be impossible, a replacement for the individual must be chosen.

Ineligible company disclosure*

I DO NOT have a financial relationship with an ineligible company
I HAVE a financial relationship with an ineligible company

Print Name*

Date Field*

Signature*

The parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

I have read and agree to the terms above.

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