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Information marked with an asterisk (*)MUST BE PROVIDED. Please make sure that your e-mail address is correct. Your e-mail address will be used for further correspondence.


Presenting Author
*Name (ex.) Nancy Smith
Contact
*Street (ex.) 3-3-10 Shiba, Minatoku-ku
*City (ex.) Tokyo
*Zip (ex.) 106-0014
*Country (ex.) Japan
*Phone (ex.) 81-3-5441-7757
+
FAX (ex.) 81-3-5441-2515
+
*E-mail (ex.) info@kcs-grp.com
@
Co-author
*Name (ex.) Nancy Smith
*E-mail (ex.) info@kcs-grp.com
@
Ethics for medical research
involving human subjects
or animal experiments
*Human subjects Approved by Institutional Review Board (IRB) or ethics committee
Not approved by IRB or ethics committee but conforms to the Declaration of Helsinki and guidelines currently applied in the country of origin
Not applicable
*Animal experiments Approved by the ethics committee or conforms to guidelines on animal care and use currently applied in the country of orgin
Not applicable
Conflict of Interset
Self-Declaration Form
By Speaker

All speakers are required to disclose any financial relationship (within the past 3 years) with a biotechnology manufacturer, a pharmaceutical company, or other commercial entity that has an interest in subject matter or materials discussed in the abstract.

*1.EmployMent/Leadership
posttion/Advisory role
(US$10,000.-or more)
Yes /No
If applicable,give entities.

*2.Stock ownership
(Profit of US$10,000.-or
more/ownership of 5% or
more of total shares)
Yes /No
If applicable,give entities.

*3.Patent royalties/
Licensing fees
(US$10,000.-or more)
Yes /No
If applicable,give entities.

*4.Honoraria(e.g. lecture
fees )
(US$5,000.-or more)
Yes /No
If applicable,give entities.

*5.Fees for promotional
materials(e.g. manuscripts
fee)
(US$5,000.-or more)
Yes /No
If applicable,give entities.

*6.Research funding
(US$10,000.-or more)
Yes /No
If applicable,give entities.

*7.Others(e.g. trips,travel,
or gifts,which are not
related to research
(US$500.-or more)
Yes /No
If applicable,give entities.