Conflict of interest form

First Name *

Last Name *

Email address *

What is your position(s)/role(s) with FRS? *

List any employment, consulting, ownership, investment, or financial interests that may create a conflict with FRS activities. (Enter none if there are none.)

List any roles with other related organizations *

List any board, committee, or advisory roles with other organizations relevant to fascia research, education, or healthcare. (Enter none if there are none.)

Financial, vendor, or leadership ties *

List any family members with financial, vendor, or leadership ties that may overlap with FRS. (Enter none if there are none.)

Potential conflict(s) of interest *

Please report any talks, presentations, events, or organizational activities that you are hosting, speaking at, or otherwise participating in that relate to fascia and could represent a potential conflict of interest. (Enter NA if not relevant.)

I have described any potential conflicts above and will recuse myself from related discussions or votes. *

Please sign by typing your name and date. *

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Fascia Research Society

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