SIR and SIR Foundation Conflict of Interest Disclosure Form

I hereby acknowledge that, as a volunteer leader or senior administrative employee of the Society of Interventional Radiology (“the Society”), I occupy a position of trust and that I am expected to act at all times in good faith with undivided loyalty to the Society, to avoid situations in which my personal and other outside interests conflict with my duty to the Society and to act in such a manner as to avoid even the appearance of using my position to advance, in a way inconsistent with the purposes and interests of the Society, any private interest of mine or any individual or entity with whom I have a significant relationship. I hereby certify that, to the best of my knowledge, no aspect of my current personal or professional circumstances places me in the position of having a private interest which is in conflict with any interest of the Society or with my obligations to the Society, except perhaps with respect to the affiliations listed below. I invite any further review by the Society of any aspects of these affiliations. I will take necessary steps to resolve any actual, apparent, or potential conflicts of interest, such as avoiding participation in deliberations, or voting on issues for which my other affiliations present an actual, apparent or potential conflict of interest with the Society’s interests. If a serious conflict cannot be resolved through disclosure and recusal from debate and voting, I will voluntarily step down from my position in the Society for which conflict exists.

Please click here to review the SIR Conflict of Interest Policy.

Describe any outside affiliations below. All responses to which you respond "YES" must include detail in the box below the item.

I also acknowledge my continuing obligation to report to the Secretary of the Society, promptly and in writing, any change in the nature or setting of my professional activities or any possible conflict of interest which comes to my attention in the future. By typing your name and the date in the boxes below, you are signing this form electronically.