{"id":2726,"date":"2017-08-28T18:06:53","date_gmt":"2017-08-28T22:06:53","guid":{"rendered":"https:\/\/www.aae.org\/specialty\/education\/find-a-speaker\/recommended-speakers-list-funding-2\/"},"modified":"2026-01-23T10:02:41","modified_gmt":"2026-01-23T16:02:41","slug":"become-a-speaker","status":"publish","type":"page","link":"https:\/\/www.aae.org\/specialty\/education-events\/find-a-speaker\/become-a-speaker\/","title":{"rendered":"Become a Speaker"},"content":{"rendered":"\n\n\t<p>Thank you for your interest in the Recommended Speakers List. Please review the Recommended Speakers List criteria prior to submitting an online form. This criteria will be used by the Continuing Education Committee and Board of Directors in reviewing your submission.<\/p>\n<p>The CEC encourages recommended speakers to address the advantages of ethically based treatment planning and to include\u00a0<a title=\"case assessment and referral tools\" href=\"https:\/\/www.aae.org\/specialty\/clinical-resources\/treatment-planning\/case-assessment-tools\/\" data-feathr-click-track=\"true\" data-feathr-link-aids=\"[&quot;636d5f3cb6ec0e11f062f95e&quot;]\">case assessment and referral tools<\/a>. Whenever possible, emphasize that the standard of care in endodontic treatment is the same for a general dentist as it is for an endodontist. The CEC also encourages its recommended speakers return their completed attendee evaluations for speaking at meetings as a result of their inclusion on the AAE Recommended Speakers List.<\/p>\n<h3>Recommended Speakers List Criteria<\/h3>\n<ul>\n<li>AAE Active Member (Active, Active 1<sup>st<\/sup>, Active 2<sup>nd<\/sup>, Associate, Disabled Active, Educator, FDHS, International, Life, and Retired).<\/li>\n<li>Expertise in one or more areas of interest that is\/are pertinent to the specialty of endodontics.<\/li>\n<li>Presented at an AAE meeting or webinar in the last five years.<\/li>\n<li>Excellent presentation skills and well-received by meeting audiences, <em>e.<\/em> demonstrated by favorable feedback from recent AAE presentations based on AAE evaluation reports, as well as reports from speaking at state, national, and international meetings, if available.<\/li>\n<li>Publications in peer-reviewed dental periodicals, which do not need to be published on the proposed topic(s).<\/li>\n<li>Shared vision and values of the AAE.<\/li>\n<li>Disclosure of all proprietary, financial or other personal interests. If speakers meet all criteria, disclosed conflict of interest information does not preclude a speaker from being approved as a recommended speaker.<\/li>\n<\/ul>\n<h3>Approved Recommended Speakers List Topics<\/h3>\n\t<ul>\n<li>AAE Foundation<\/li>\n<li>CBCT<\/li>\n<li>Differential Diagnosis<\/li>\n<li>Emergency Treatment<\/li>\n<li>Endodontic and Periodontic Interactions<\/li>\n<li>Endodontic\u00a0Microsurgery<\/li>\n<li>Endodontics and the Law<\/li>\n<li>Endodontics vs Single-Tooth Implants<\/li>\n<li>General Endodontic Knowledge<\/li>\n<li>Geriatric Endodontics<\/li>\n<li>Microbiology\u00a0and Host Responses<\/li>\n<\/ul>\n\t<ul>\n<li>Nonsurgical Endodontic Treatment and Retreatment<\/li>\n<li>Outcome Assessment<\/li>\n<li>Pharmacology<\/li>\n<li>Problem Solving in Endodontics<\/li>\n<li>Regenerative Endodontics<\/li>\n<li>Research<\/li>\n<li>Resorption<\/li>\n<li>Restorative Endodontics<\/li>\n<li>Traumatic Injuries Diagnosis and Treatment<\/li>\n<li>Vital Pulp Therapy<\/li>\n<\/ul>\n\t<h2>Ready to apply to get listed as a speaker?<\/h2>\n<p>If you meet ALL of the above criteria and have a lecture on an approved topic, simply complete the form below.<\/p>\n<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_1' style='display:none'><div id='gf_1' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/specialty\/wp-json\/wp\/v2\/pages\/2726#gf_1' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_page_1_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_above validation_below'><li id=\"field_1_7\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Your Information<\/h2><\/li><li id=\"field_1_3\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Full Name (including all professional credentials)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name has_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_1_3'>\n                            \n                            <span id='input_1_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.3' id='input_1_3_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_3_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_3_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.6' id='input_1_3_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_3_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <span id='input_1_3_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.8' id='input_1_3_8' value=''   aria-required='false'     \/>\n                                                    <label for='input_1_3_8' class='gform-field-label gform-field-label--type-sub '>Credentials<\/label>\n                                                <\/span>\n                        <\/div><\/li><li id=\"field_1_2\" class=\"gfield gfield--type-address gfield--input-type-address field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_1_2' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_2_1_container' >\n                                        <input type='text' name='input_2.1' id='input_1_2_1' value=''    aria-required='false'    \/>\n                                        <label for='input_1_2_1' id='input_1_2_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_2_2_container' >\n                                        <input type='text' name='input_2.2' id='input_1_2_2' value=''     aria-required='false'   \/>\n                                        <label for='input_1_2_2' id='input_1_2_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_2_3_container' >\n                                    <input type='text' name='input_2.3' id='input_1_2_3' value=''    aria-required='false'    \/>\n                                    <label for='input_1_2_3' id='input_1_2_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_2_4_container' >\n                                        <input type='text' name='input_2.4' id='input_1_2_4' value=''      aria-required='false'    \/>\n                                        <label for='input_1_2_4' id='input_1_2_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_2_5_container' >\n                                    <input type='text' name='input_2.5' id='input_1_2_5' value=''    aria-required='false'    \/>\n                                    <label for='input_1_2_5' id='input_1_2_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_1_2_6_container' >\n                                        <select name='input_2.6' id='input_1_2_6'   aria-required='false'    ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' selected='selected'>United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_1_2_6' id='input_1_2_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_1_4\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_4'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_1_4' type='tel' value='' class='small'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_6\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_6'>Fax<\/label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_1_6' type='tel' value='' class='small'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_5\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_5'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_1_5' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_1_9\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_9'>Current AAE Member Type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_9' id='input_1_9' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select Member Type<\/option><option value='Active' >Active<\/option><option value='Active First Year' >Active First Year<\/option><option value='Active Second Year' >Active Second Year<\/option><option value='Associate' >Associate<\/option><option value='Auxiliary' >Auxiliary<\/option><option value='Disabled Active' >Disabled Active<\/option><option value='Educator' >Educator<\/option><option value='FDHS' >FDHS<\/option><option value='Honorary' >Honorary<\/option><option value='International' >International<\/option><option value='International First Year' >International First Year<\/option><option value='International Resident' >International Resident<\/option><option value='International Second Year' >International Second Year<\/option><option value='Life' >Life<\/option><option value='Predoctoral Student' >Predoctoral Student<\/option><option value='Resident' >Resident<\/option><option value='Retired' >Retired<\/option><\/select><\/div><\/li><li id=\"field_1_8\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Speaker Details<\/h2><\/li><li id=\"field_1_12\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_12'>At which recent AAE meetings and state\/national meetings have you been invited to speak?<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_1_12' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_10\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_10'>Please list your publications in peer-reviewed dental periodicals (you do not need to be published on your proposed topic)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_10' id='input_1_10' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_22\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_22'>Biography:  Please provide a brief biography.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_22' id='input_1_22' class='textarea medium'   maxlength='1500'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_14\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Presentation Details<\/h2><\/li><li id=\"field_1_11\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_11'>Presentation Topic<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_11' id='input_1_11' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select Topic<\/option><option value='AAE Foundation' >AAE Foundation<\/option><option value='CBCT' >CBCT<\/option><option value='Differential Diagnosis' >Differential Diagnosis<\/option><option value='Emergency Treatment' >Emergency Treatment<\/option><option value='Endodontic and Periodontic Interactions' >Endodontic and Periodontic Interactions<\/option><option value='Endodontic\u00a0Microsurgery' >Endodontic\u00a0Microsurgery<\/option><option value='Endodontics and the Law' >Endodontics and the Law<\/option><option value='Endodontics vs Single-Tooth Implants' >Endodontics vs Single-Tooth Implants<\/option><option value='General Endodontic Knowledge' >General Endodontic Knowledge<\/option><option value='Geriatric Endodontics' >Geriatric Endodontics<\/option><option value='Microbiology\u00a0and Host Responses' >Microbiology\u00a0and Host Responses<\/option><option value='Nonsurgical Endodontic Treatment and Retreatment' >Nonsurgical Endodontic Treatment and Retreatment<\/option><option value='Outcome Assessment' >Outcome Assessment<\/option><option value='Pharmacology' >Pharmacology<\/option><option value='Problem Solving in Endodontics' >Problem Solving in Endodontics<\/option><option value='Regenerative Endodontics' >Regenerative Endodontics<\/option><option value='Research' >Research<\/option><option value='Resorption' >Resorption<\/option><option value='Restorative Endodontics' >Restorative Endodontics<\/option><option value='Traumatic Injuries Diagnosis and Treatment' >Traumatic Injuries Diagnosis and Treatment<\/option><option value='Vital Pulp Therapy' >Vital Pulp Therapy<\/option><\/select><\/div><\/li><li id=\"field_1_16\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_16'>Presentation Title<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_1_16' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_13\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_13'>Presentation Brief Session Description<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_13' id='input_1_13' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_1_19\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Presentation Length<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_19'><li class='gchoice gchoice_1_19_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.1' type='checkbox'  value='Half Day'  id='choice_1_19_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_19_1' id='label_1_19_1' class='gform-field-label gform-field-label--type-inline'>Half Day<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_19_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.2' type='checkbox'  value='Full Day'  id='choice_1_19_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_19_2' id='label_1_19_2' class='gform-field-label gform-field-label--type-inline'>Full Day<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_19_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.3' type='checkbox'  value='Two Days'  id='choice_1_19_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_19_3' id='label_1_19_3' class='gform-field-label gform-field-label--type-inline'>Two Days<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_19_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.4' type='checkbox'  value='Other (please specify below)'  id='choice_1_19_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_19_4' id='label_1_19_4' class='gform-field-label gform-field-label--type-inline'>Other (please specify below)<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_23\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_23'>If you answered other in the question above, please specify<\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_1_23' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_21\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Presentation Format<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_21'><li class='gchoice gchoice_1_21_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.1' type='checkbox'  value='Lecture'  id='choice_1_21_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_1' id='label_1_21_1' class='gform-field-label gform-field-label--type-inline'>Lecture<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_21_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.2' type='checkbox'  value='Workshop'  id='choice_1_21_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_2' id='label_1_21_2' class='gform-field-label gform-field-label--type-inline'>Workshop<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_21_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.3' type='checkbox'  value='Live Demo'  id='choice_1_21_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_21_3' id='label_1_21_3' class='gform-field-label gform-field-label--type-inline'>Live Demo<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_15\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Learning Objectives<\/h2><div class='gsection_description' id='gfield_description_1_15'>Provide three learning objectives that complete the following sentence \n\"At the conclusion, participants should be able to:\u201d \nLearning objectives should include measurable verbs, i.e. use the measurable verb \u201cdescribe\u201d instead of the non-measurable verb \u201cunderstand\u201d.<\/div><\/li><li id=\"field_1_17\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_17'>Learning Objective 1<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_1_17' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_18\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_18'>Learning Objective 2<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_1_18' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_20\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_20'>Learning Objective 3<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_1_20' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_1_26' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_2' class='gform_page' data-js='page-field-id-26' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_1_2' class='gform_fields top_label form_sublabel_below description_above validation_below'><li id=\"field_1_28\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  >Each program participant must provide his\/her understanding and disclosure of any conflict of interest, whether or not related to the presentation, and the prospective audience must be made aware of the affiliation\/interest through notice in the program and verbally at the beginning of the presentation. Having an interest in a product, service, course or company does not necessarily preclude a speaker's participation or affect the status of the speaker. The purpose of collecting this information is to share it with the membership and\/or attendees to help them gain perspective on the presentations and to operate within the guidelines of ADA CERP. In deciding what to disclose, all speakers should carefully consider whether any particular affiliation(s) could cause embarrassment to the speaker or the AAE or whether it could lead to questions regarding the speaker's motives if such affiliation(s) were made public. All speakers should exercise particular care that no detriment to the AAE will result from conflicts between self interest and those of the AAE.<\/li><li id=\"field_1_29\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Select one of the following statements:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_29'>\n\t\t\t<li class='gchoice gchoice_1_29_0'>\n\t\t\t\t<input name='input_29' type='radio' value='In accordance with this policy, I declare that I have NO past or present proprietary or relevant financial relationship or receive gifts in kind (including soft intangible remuneration), consulting position or affiliation, or other personal interest of any nature or kind in any product, service, course and\/or company, or in any firm beneficially associated therewith.'  id='choice_1_29_0'    \/>\n\t\t\t\t<label for='choice_1_29_0' id='label_1_29_0' class='gform-field-label gform-field-label--type-inline'>In accordance with this policy, I declare that I have NO past or present proprietary or relevant financial relationship or receive gifts in kind (including soft intangible remuneration), consulting position or affiliation, or other personal interest of any nature or kind in any product, service, course and\/or company, or in any firm beneficially associated therewith.<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_29_1'>\n\t\t\t\t<input name='input_29' type='radio' value='In accordance with this policy, I declare I have a past or present proprietary or relevant financial relationship or receive gifts in kind (including soft intangible remuneration), consulting position or affiliation, or other personal interest of any nature or kind in any product, service, course and\/or company, or in any firm beneficially associated therewith, as indicated below.'  id='choice_1_29_1'    \/>\n\t\t\t\t<label for='choice_1_29_1' id='label_1_29_1' class='gform-field-label gform-field-label--type-inline'>In accordance with this policy, I declare I have a past or present proprietary or relevant financial relationship or receive gifts in kind (including soft intangible remuneration), consulting position or affiliation, or other personal interest of any nature or kind in any product, service, course and\/or company, or in any firm beneficially associated therewith, as indicated below.<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_39\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_39'>Electronic Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_39'>Please type your first and last name.<\/div><div class='ginput_container ginput_container_text'><input name='input_39' id='input_1_39' type='text' value='' class='medium'  aria-describedby=\"gfield_description_1_39\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_32\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Financial Relationships<\/h2><div class='gsection_description' id='gfield_description_1_32'> Please indicate each relationship, financial interest, corporate, institutional or educational entity and whether it is past or present.<\/div><\/li><li id=\"field_1_41\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_41'>Company Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_1_41' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_34\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Individual(s) Involved<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_34'>Select who has the financial relationship with the company listed above. (Check all that apply.)<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_34'><li class='gchoice gchoice_1_34_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.1' type='checkbox'  value='Self'  id='choice_1_34_1'   aria-describedby=\"gfield_description_1_34\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_1' id='label_1_34_1' class='gform-field-label gform-field-label--type-inline'>Self<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_34_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.2' type='checkbox'  value='Spouse\/Partner'  id='choice_1_34_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_2' id='label_1_34_2' class='gform-field-label gform-field-label--type-inline'>Spouse\/Partner<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_35\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Type of Financial Relationship<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_35'>(Check all that apply.)<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_35'><li class='gchoice gchoice_1_35_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.1' type='checkbox'  value='Grant\/Research Support'  id='choice_1_35_1'   aria-describedby=\"gfield_description_1_35\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_35_1' id='label_1_35_1' class='gform-field-label gform-field-label--type-inline'>Grant\/Research Support<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_35_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.2' type='checkbox'  value='Consultant'  id='choice_1_35_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_35_2' id='label_1_35_2' class='gform-field-label gform-field-label--type-inline'>Consultant<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_35_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.3' type='checkbox'  value='Stockholder\/Ownership Interest (excluding diversified mutual funds)'  id='choice_1_35_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_35_3' id='label_1_35_3' class='gform-field-label gform-field-label--type-inline'>Stockholder\/Ownership Interest (excluding diversified mutual funds)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_35_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.4' type='checkbox'  value='Honorarium'  id='choice_1_35_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_35_4' id='label_1_35_4' class='gform-field-label gform-field-label--type-inline'>Honorarium<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_35_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.5' type='checkbox'  value='Other Financial or Materials Support'  id='choice_1_35_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_35_5' id='label_1_35_5' class='gform-field-label gform-field-label--type-inline'>Other Financial or Materials Support<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_40\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_40'>If other, please specify.<\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_1_40' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_37\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Status of Financial Relationship<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_37'><li class='gchoice gchoice_1_37_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.1' type='checkbox'  value='Ongoing'  id='choice_1_37_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_37_1' id='label_1_37_1' class='gform-field-label gform-field-label--type-inline'>Ongoing<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_37_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_37.2' type='checkbox'  value='Terminated'  id='choice_1_37_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_37_2' id='label_1_37_2' class='gform-field-label gform-field-label--type-inline'>Terminated<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_38\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_38'>If terminated, please provide the date ended:<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_1_38' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_42\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Disclose another financial relationship?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_42'>\n\t\t\t<li class='gchoice gchoice_1_42_0'>\n\t\t\t\t<input name='input_42' type='radio' value='No'  id='choice_1_42_0'    \/>\n\t\t\t\t<label for='choice_1_42_0' id='label_1_42_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_42_1'>\n\t\t\t\t<input name='input_42' type='radio' value='Yes'  id='choice_1_42_1'    \/>\n\t\t\t\t<label for='choice_1_42_1' id='label_1_42_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_43\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_43'>Company Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_1_43' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_44\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Individual(s) Involved<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_44'>Select who has the financial relationship with the company listed above. (Check all that apply.)<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_44'><li class='gchoice gchoice_1_44_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.1' type='checkbox'  value='Self'  id='choice_1_44_1'   aria-describedby=\"gfield_description_1_44\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_44_1' id='label_1_44_1' class='gform-field-label gform-field-label--type-inline'>Self<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_44_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.2' type='checkbox'  value='Spouse\/Partner'  id='choice_1_44_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_44_2' id='label_1_44_2' class='gform-field-label gform-field-label--type-inline'>Spouse\/Partner<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_45\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Type of Financial Relationship<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_45'>(Check all that apply.)<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_45'><li class='gchoice gchoice_1_45_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.1' type='checkbox'  value='Grant\/Research Support'  id='choice_1_45_1'   aria-describedby=\"gfield_description_1_45\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_45_1' id='label_1_45_1' class='gform-field-label gform-field-label--type-inline'>Grant\/Research Support<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_45_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.2' type='checkbox'  value='Consultant'  id='choice_1_45_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_45_2' id='label_1_45_2' class='gform-field-label gform-field-label--type-inline'>Consultant<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_45_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.3' type='checkbox'  value='Stockholder\/Ownership Interest (excluding diversified mutual funds)'  id='choice_1_45_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_45_3' id='label_1_45_3' class='gform-field-label gform-field-label--type-inline'>Stockholder\/Ownership Interest (excluding diversified mutual funds)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_45_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.4' type='checkbox'  value='Honorarium'  id='choice_1_45_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_45_4' id='label_1_45_4' class='gform-field-label gform-field-label--type-inline'>Honorarium<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_45_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.5' type='checkbox'  value='Other Financial or Materials Support'  id='choice_1_45_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_45_5' id='label_1_45_5' class='gform-field-label gform-field-label--type-inline'>Other Financial or Materials Support<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_46\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_46'>If other, please specify.<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_1_46' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_47\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Status of Financial Relationship<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_47'><li class='gchoice gchoice_1_47_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.1' type='checkbox'  value='Ongoing'  id='choice_1_47_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_47_1' id='label_1_47_1' class='gform-field-label gform-field-label--type-inline'>Ongoing<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_47_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.2' type='checkbox'  value='Terminated'  id='choice_1_47_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_47_2' id='label_1_47_2' class='gform-field-label gform-field-label--type-inline'>Terminated<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_48\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_48'>If terminated, please provide the date ended:<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_1_48' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_49\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Disclose another financial relationship?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_49'>\n\t\t\t<li class='gchoice gchoice_1_49_0'>\n\t\t\t\t<input name='input_49' type='radio' value='No'  id='choice_1_49_0'    \/>\n\t\t\t\t<label for='choice_1_49_0' id='label_1_49_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_49_1'>\n\t\t\t\t<input name='input_49' type='radio' value='Yes'  id='choice_1_49_1'    \/>\n\t\t\t\t<label for='choice_1_49_1' id='label_1_49_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_50\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_50'>Company Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_1_50' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_51\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Individual(s) Involved<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_51'>Select who has the financial relationship with the company listed above. (Check all that apply.)<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_51'><li class='gchoice gchoice_1_51_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.1' type='checkbox'  value='Self'  id='choice_1_51_1'   aria-describedby=\"gfield_description_1_51\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_51_1' id='label_1_51_1' class='gform-field-label gform-field-label--type-inline'>Self<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_51_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.2' type='checkbox'  value='Spouse\/Partner'  id='choice_1_51_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_51_2' id='label_1_51_2' class='gform-field-label gform-field-label--type-inline'>Spouse\/Partner<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_52\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Type of Financial Relationship<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_1_52'>(Check all that apply.)<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_52'><li class='gchoice gchoice_1_52_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.1' type='checkbox'  value='Grant\/Research Support'  id='choice_1_52_1'   aria-describedby=\"gfield_description_1_52\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_52_1' id='label_1_52_1' class='gform-field-label gform-field-label--type-inline'>Grant\/Research Support<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_52_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.2' type='checkbox'  value='Consultant'  id='choice_1_52_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_52_2' id='label_1_52_2' class='gform-field-label gform-field-label--type-inline'>Consultant<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_52_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.3' type='checkbox'  value='Stockholder\/Ownership Interest (excluding diversified mutual funds)'  id='choice_1_52_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_52_3' id='label_1_52_3' class='gform-field-label gform-field-label--type-inline'>Stockholder\/Ownership Interest (excluding diversified mutual funds)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_52_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.4' type='checkbox'  value='Honorarium'  id='choice_1_52_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_52_4' id='label_1_52_4' class='gform-field-label gform-field-label--type-inline'>Honorarium<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_52_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.5' type='checkbox'  value='Other Financial or Materials Support'  id='choice_1_52_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_52_5' id='label_1_52_5' class='gform-field-label gform-field-label--type-inline'>Other Financial or Materials Support<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_53\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_53'>If other, please specify.<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_1_53' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_54\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Status of Financial Relationship<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_54'><li class='gchoice gchoice_1_54_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.1' type='checkbox'  value='Ongoing'  id='choice_1_54_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_54_1' id='label_1_54_1' class='gform-field-label gform-field-label--type-inline'>Ongoing<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_54_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.2' type='checkbox'  value='Terminated'  id='choice_1_54_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_54_2' id='label_1_54_2' class='gform-field-label gform-field-label--type-inline'>Terminated<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_55\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_55'>If terminated, please provide the date ended:<\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_1_55' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_56\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Disclose another financial relationship?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_56'>\n\t\t\t<li class='gchoice gchoice_1_56_0'>\n\t\t\t\t<input name='input_56' type='radio' value='No'  id='choice_1_56_0'    \/>\n\t\t\t\t<label for='choice_1_56_0' id='label_1_56_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_56_1'>\n\t\t\t\t<input name='input_56' type='radio' value='Yes'  id='choice_1_56_1'    \/>\n\t\t\t\t<label for='choice_1_56_1' id='label_1_56_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_57\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_57'>Company Name<\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_1_57' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_58\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Individual(s) Involved<\/label><div class='gfield_description' id='gfield_description_1_58'>Select who has the financial relationship with the company listed above. (Check all that apply.)<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_58'><li class='gchoice gchoice_1_58_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.1' type='checkbox'  value='Self'  id='choice_1_58_1'   aria-describedby=\"gfield_description_1_58\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_1' id='label_1_58_1' class='gform-field-label gform-field-label--type-inline'>Self<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_58_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.2' type='checkbox'  value='Spouse\/Partner'  id='choice_1_58_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_58_2' id='label_1_58_2' class='gform-field-label gform-field-label--type-inline'>Spouse\/Partner<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_59\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Type of Financial Relationship<\/label><div class='gfield_description' id='gfield_description_1_59'>(Check all that apply.)<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_59'><li class='gchoice gchoice_1_59_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.1' type='checkbox'  value='Grant\/Research Support'  id='choice_1_59_1'   aria-describedby=\"gfield_description_1_59\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_59_1' id='label_1_59_1' class='gform-field-label gform-field-label--type-inline'>Grant\/Research Support<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_59_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.2' type='checkbox'  value='Consultant'  id='choice_1_59_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_59_2' id='label_1_59_2' class='gform-field-label gform-field-label--type-inline'>Consultant<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_59_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.3' type='checkbox'  value='Stockholder\/Ownership Interest (excluding diversified mutual funds)'  id='choice_1_59_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_59_3' id='label_1_59_3' class='gform-field-label gform-field-label--type-inline'>Stockholder\/Ownership Interest (excluding diversified mutual funds)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_59_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.4' type='checkbox'  value='Honorarium'  id='choice_1_59_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_59_4' id='label_1_59_4' class='gform-field-label gform-field-label--type-inline'>Honorarium<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_59_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.5' type='checkbox'  value='Other Financial or Materials Support'  id='choice_1_59_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_59_5' id='label_1_59_5' class='gform-field-label gform-field-label--type-inline'>Other Financial or Materials Support<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_60\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_60'>If other, please specify.<\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_1_60' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_61\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Status of Financial Relationship<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_61'><li class='gchoice gchoice_1_61_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.1' type='checkbox'  value='Ongoing'  id='choice_1_61_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_61_1' id='label_1_61_1' class='gform-field-label gform-field-label--type-inline'>Ongoing<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_61_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.2' type='checkbox'  value='Terminated'  id='choice_1_61_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_61_2' id='label_1_61_2' class='gform-field-label gform-field-label--type-inline'>Terminated<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_62\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_62'>If terminated, please provide the date ended:<\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_1_62' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_63\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Disclose another financial relationship?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_1_63'>\n\t\t\t<li class='gchoice gchoice_1_63_0'>\n\t\t\t\t<input name='input_63' type='radio' value='No'  id='choice_1_63_0'    \/>\n\t\t\t\t<label for='choice_1_63_0' id='label_1_63_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_1_63_1'>\n\t\t\t\t<input name='input_63' type='radio' value='Yes'  id='choice_1_63_1'    \/>\n\t\t\t\t<label for='choice_1_63_1' id='label_1_63_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_64\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_64'>Company Name<\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_1_64' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_65\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Individual(s) Involved<\/label><div class='gfield_description' id='gfield_description_1_65'>Select who has the financial relationship with the company listed above. (Check all that apply.)<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_65'><li class='gchoice gchoice_1_65_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.1' type='checkbox'  value='Self'  id='choice_1_65_1'   aria-describedby=\"gfield_description_1_65\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_65_1' id='label_1_65_1' class='gform-field-label gform-field-label--type-inline'>Self<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_65_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.2' type='checkbox'  value='Spouse\/Partner'  id='choice_1_65_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_65_2' id='label_1_65_2' class='gform-field-label gform-field-label--type-inline'>Spouse\/Partner<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_66\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Type of Financial Relationship<\/label><div class='gfield_description' id='gfield_description_1_66'>(Check all that apply.)<\/div><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_66'><li class='gchoice gchoice_1_66_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_66.1' type='checkbox'  value='Grant\/Research Support'  id='choice_1_66_1'   aria-describedby=\"gfield_description_1_66\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_1_66_1' id='label_1_66_1' class='gform-field-label gform-field-label--type-inline'>Grant\/Research Support<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_66_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_66.2' type='checkbox'  value='Consultant'  id='choice_1_66_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_66_2' id='label_1_66_2' class='gform-field-label gform-field-label--type-inline'>Consultant<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_66_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_66.3' type='checkbox'  value='Stockholder\/Ownership Interest (excluding diversified mutual funds)'  id='choice_1_66_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_66_3' id='label_1_66_3' class='gform-field-label gform-field-label--type-inline'>Stockholder\/Ownership Interest (excluding diversified mutual funds)<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_66_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_66.4' type='checkbox'  value='Honorarium'  id='choice_1_66_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_66_4' id='label_1_66_4' class='gform-field-label gform-field-label--type-inline'>Honorarium<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_66_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_66.5' type='checkbox'  value='Other Financial or Materials Support'  id='choice_1_66_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_66_5' id='label_1_66_5' class='gform-field-label gform-field-label--type-inline'>Other Financial or Materials Support<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_67\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_67'>If other, please specify.<\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_1_67' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_68\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Status of Financial Relationship<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_68'><li class='gchoice gchoice_1_68_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.1' type='checkbox'  value='Ongoing'  id='choice_1_68_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_68_1' id='label_1_68_1' class='gform-field-label gform-field-label--type-inline'>Ongoing<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_1_68_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.2' type='checkbox'  value='Terminated'  id='choice_1_68_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_68_2' id='label_1_68_2' class='gform-field-label gform-field-label--type-inline'>Terminated<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_1_69\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_69'>If terminated, please provide the date ended:<\/label><div class='ginput_container ginput_container_text'><input name='input_69' id='input_1_69' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><\/ul><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_1' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='submit' id='gform_submit_button_1' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_1' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_1' id='gform_theme_1' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_1' id='gform_style_settings_1' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='1' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='uBkCLbImCGn5DSgSTXaMGXH7wB0NTSmcAeEiXne6OCg46apb2FGF5\/d\/T2YzNrACQKN5hId0NTjYhG5gkK0qzc7UK2WYuKcBR1j3uPJnUdWbnU8=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' value='WyJbXSIsImQwMmM5YjI4MDI5MGZlYWVjMTJkY2ZjZGJhMTEzNjg2Il0=' \/>\n            <input type='hidden' 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