MANDATE FORM

SOUTH AFRICAN ORTHOPAEDIC ASSOCIATION

65 Kellner Street , Kellner Park , Suite 10 , Westdene, Bloemfontein 9301 SOUTH AFRICA

This form is to be completed by all Authors who have had their presentation accepted.

Mandatory Financial Disclosure Statement

Click here to download the document. Once completed please send it to saoa@connix.co.za or
fax to +27 (0)51 4303 284

The South African Orthopaedic Association is the accredited sponsor of Continuing Medical Education (CME).

This form must be completed by all participants who submitted papers or posters.

Please place a check in the box opposite the statement which applies to you. If you have a financial interest or other relationship with a commercial company related directly or indirectly with the South African Orthopaedic Association, place a check in the first box. Also include the name of the commercial company. Your disclosure will be listed in the final programme.

The SAOA does not view the existence of these interests or commitments as necessarily implying bias or decreasing the value of your participation in the Association's activities.
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Please select one of the following
I (or a member of my immediate family) has a financial interest or other relationship with a commercial company related directly or indirectly with the South African Orthopaedic Association in respect of my paper/poster.

  Check all that apply:

a . Research or institutional support has been received from:

(Name of company or companies)

b. Miscellaneous non-income support (e.g. equipment or services,) commercially derived honoraria, or other non-research related funding (e.g. paid travel) has been received from :

(Name of company or companies)
c. Royalties have been received from:

(Name of company or companies)
d. Stock or stock options held in :

(Name of company or companies)
e. Consultant or employee

(Name of company or companies)
2. I (or a member of my immediate family) do not have a financial interest or other relationship with a commercial company related directly or indirectly with the South African Orthopaedic Association in respect of my paper/poster being
 

PLEASE FAX FORM TO LéANA FOURIE AT +27 51 4303 284 BY 30 JUNE 2008

I hereby confirm that the above details have been filled in correctly.