Appendix 2 Biographical Data/Vested Interest Form -
Must be completed and included in the application packet.
This form combines the previous Biographical Data and Vested Interest forms into one form. Note that Vested Interest information must now be provided to the AARC

Instructions: Please complete the entire form and make as many copies of it as necessary. Do not attach any additional material, such as curriculum vitae.

Vested Interest
Note: (i) This section must be completed for all individuals identified in the documentation of educational activities.
(ii) Alternatively, special forms that identify a vested interest may be submitted in place of the section below.
Definition: An individual involved in the planning of or presentation of an educational activity may have an interest in or affiliation with an organization but the audience must be informed of this relationship before the presentation of the activity. For this purpose, a real or apparent conflict of interest is defined as personal gain or benefit derived from involvement with any entity, product or service. Vested Interest includes but is not limited to employment, by owning stock, from inclusion in a speakers’ bureau or a relationship, personal or otherwise, with a company that could potentially benefit from the relationship.
I recognize that I must follow all criteria regarding vested interest and declare that:

This information must be provided to the program participants.

Required to Check this box