Conflict of Interest Disclosure
Biomedical Research Grant Applicant
Applicant Name
Email Address
Institution / Organization
Financial Interests
Do you or your immediate family have any financial relationship with entities that may have an interest in the subject matter of this research?
Yes
No
If yes, please describe (include organization, nature of interest, and amount):
Intellectual Property
Do you have any intellectual property (patents, copyrights, etc.) related to the research?
Yes
No
If yes, please describe:
Other Relationships
Do you have any other affiliations, relationships, or circumstances that might be perceived as a potential conflict of interest?
Yes
No
If yes, please describe:
Certification
I certify that the above information is complete and accurate to the best of my knowledge.
I agree
Signature
Date