<p> Pennsylvania Pharmacists Association Speaker Disclosure Declaration All speakers (in this case this means, any student or individual present for the poster presentation) for any CPE program shall, prior to the first presentation of the program, complete, sign, and return the below Speaker Disclosure Declaration form to the CPE Administrator. If any presenter fails to return or declines to complete this disclosure form, this is automatic reason for removal as the speaker and possible program cancellation, if another presenter cannot be found. PPA’s CPE Administrator, upon receipt of a speaker disclosure, shall automatically review it for any concerns of potential conflicts of interest. If there are any apparent conflicts or even possible concerns, the CPE Administrator will immediately contact the presenter to attempt to resolve or remove such conflicts. PPA will not tolerate any conflict of interest or commercial bias in any CPE presentations. Information provided on this form will be provided to program participants prior to the presentation. If commercial support for a CPE program is received, PPA’s CPE Administrator will contact the speaker to affirm that there is no relevant relationship that may impact the content of the presentation.</p><p>Please provide the information requested below regarding any affiliation or financial interest with any corporate organization. ☐ I have (or an immediate family member has) a vested interest in or affiliation with an organization whose philosophy could potentially bias my presentation, has a specific commercial service or interest in the therapeutic areas, drugs, and/or devices under discussion, or a corporate organization offering financial support or grant monies for this continuing education program, as follows: Indicate the type of relationship and name of the organization: Relationship Corporate Organization</p><p>Grant/Research Support ______</p><p>Consultant ______</p><p>Stock Shareholder (directly purchased) ______</p><p>Speaker with honorarium ______</p><p>Other Financial or Material Support ______</p><p>Other Affiliation ______</p><p>☐ I do not have (nor does any immediate family have) a vested interest in or affiliation with an organization whose philosophy could potentially bias my presentation, has a specific commercial service or interest in the therapeutic areas, drugs, and/or devices under discussion, or a corporate organization offering financial support or grant monies for this continuing education program. This disclosure is a requirement for ACPE accreditation of PPA as a provider of continuing education for pharmacists. Failure to disclose a vested interest, possible vested interest, or a false disclosure will require the Pennsylvania Pharmacists Association to cancel a program or identify a replacement. Name: (Please Print) Signature: Date:</p><p>Complete and submit this form to PPA Mail to: 508 North Third Street, Harrisburg, PA 17101-1199 Fax to: (717) 236-1618 E-mail to: [email protected]</p>