Please read this statement, complete the form with the appropriate information, sign, and return with your Volunteer Application . To the best of my knowledge, neither I nor any member of my immediate family has a real or perceived conflict of interest with the American Board of Radiology (ABR) except as listed in the spaces below.
FOR EACH "YES" ANSWER TO THE FOLLOWING QUESTIONS, PLEASE EXPLAIN IN THE SPACE PROVIDED.
Work for Hire
By initialing the spaces below, I indicate my commitment to the following duties of volunteers, which support the Board’s aims of both undivided allegiance to the organization’s mission and goals and avoidance of any undue influence over ABR decisions.
I have read the disclosure requirements, and to the best of my knowledge, the information I have provided on this form is true and correct and represents all items for disclosure. I understand that failure to comply with the Conflict of Interest Policy may result in a two-year disqualification from participating in ABR committees or related activities. I also agree to notify the ABR promptly if any of the information in this form changes.
If I am submitting this electronically, by clicking “Submit,” I acknowledge and agree that I bind and legally obligate myself to the same extent as I would by signing my name on a printed version of this form.