Declaration of Interests

Title:

First Name: A first name is required.* required

Last Name: A last name is required.* required

email: An email address is required.Invalid email format.* required

Phone: A phone number is required.* required

Primary Employment: Primary Employment is required.* required

1. Do you have patent/s or invention/s from which you may derive personal benefit in the area of psychopharmacology?
Yes No

If Yes, please provide details:

2. Do you have ownership or part ownership of a company with interests in the area of psychopharmacology? (This would include holding the shares of major companies in one’s own name, or those of dependent family members.)
Yes No

If Yes, please provide details:

3. Do you accept a personal retainer from any company with an interest in psychopharmacology?
Yes No

If Yes, please provide details:

4. Do you act as a consultant to any company with an interest in psychopharmacology?
Yes No

If Yes, please provide details:

5. Do you act or have you acted as an expert witness, either friendly or hostile to any company with an interest in psychopharmacology?
Yes No

If Yes, please provide details:

6. Do you hold or have you held a research grant from any company with an interest in psychopharmacology?
Yes No

If Yes, please provide details:

7. Do you hold membership of the speakers’ bureau for any company?
Yes No

If Yes, please provide details:

8. Do you accept paid speaking engagements in industry supported symposia?
Yes No

If Yes, please provide details:

9. Do you accept travel or hospitality NOT related to a speaking engagement?
Yes No

If Yes, please provide details: