International Program Committee Acceptance Please complete the survey below. If you have any questions, please contact [email protected]. International Program Service Step 1: Section/Service Representative Serving on International Program CommitteePlease provide the contact information of the section/service chair or co-chair designated to serve on the international program committee.Name* First Last Email*Please confirm your email for future correspondence. Assistant EmailPlease provide/confirm your assistant email for future correspondence. PhonePlease confirm your phone number.Step 2: CME DisclosureDisclosure of Financial Relationships*A commercial interest is defined as an entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. No. Neither I nor my spouse or partner have at present and/or have had within the last 12 months a financial relationship with a commercial interest. Yes. I and/or my spouse or partner have at present and/or have had within the last 12 months a financial relationship with a commercial interest. Financial Relationship(s):If you or your spouse/partner have at present and/or have had within the last 12 months a financial relationship with a commercial interest (A commercial interest is defined as an entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.), please list them below. To add additional lines, please click the + button to the right.Commercial Interest/CompanyFor What Role?What was Received?Myself and/or Spouse/Partner Step 3: International Program Committee SuggestionsCommittee Member Suggestions:Please provide 5-6 recommendations of individuals that would like to serve on one of the AHNS 2023 International program committees. Please use the plus sign on the right side to include additional suggestions.Individual's NameEmailInstitution Δ Share:FacebookTwitterLinkedIn