Please complete this faculty agreement and send it to the activity coordinator, along with requested information.

Joint Providership - Co-Presenter/Conflict of Interest

Contact Information


Activity Details

Please provide details of the activity.
Hosting Organization Contact Person
Event Type

Live Activity Information

MM slash DD slash YYYY

Curriculum Vitae and Biography

Submit a detailed CV via e-mail and write a short biography below for inclusion in the onsite faculty introduction. Bio should be no longer than 250 words.


Accredited activities shall exhibit fair content balance, providing the audience with information of different perspectives from which to develop an informed professional opinion. All relevant financial relationships with anyone who is in a position to control the content, including commercial interest and spouses/partners must be disclosed. In addition, should it be determined that a conflict of interest exist as a result of a financial relationship you may have, this will need to be resolved prior to the activity. This information is necessary in order for us to be able to move to the next steps in planning this activity. If you refuse to disclose relevant financial relationships, you will be disqualified from being a part of the planning and implementation of this activity. First, list the names of proprietary entities producing health care goods or services, consumed by, or used on patients, with the exemption of nonprofit or government organizations and non-health care-related companies with which you or your spouse/partner have, or have had, a relevant financial relationship in any amount within the past 24 months that create a conflict of interest. Second, describe what you received (ex: salary, honorarium, etc.) You do not need to reveal how much you received. Third, describe your role.
Disclosure Statement(Required)
Nature of Relevant Financial Relationship
Include all that apply.
Commercial Interest and Influential Relationship (Example: Company "X" or name of person(s) other than yourself controlling content)
What I received (Example: honorarium, salary royalty)
My Role (Example: speaker, employment, consultant)
What was received: Salary, royalty, intellectual property rights, consulting fee, honorarium, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit.

My role(s): Employment, management position, independent contractor(including contracted research), consulting, speaking and teaching, membership on advisory Committees or review panels, Board membership and other activities.


Faculty will indemnify Hosting Organization and Michigan Pharmacists Association (MPA) from and against all claims, including, but not limited to intellectual property infringement, copyright, damages, liabilities, expenses and judgments recovered from or asserted against Hosting Organization and/or MPA as a result of faculty presentation, materials and activities under this Agreement. Hosting Organization and MPA agrees to indemnify faculty from and against all claims, damages, liabilities, expenses and judgments recovered from or asserted against faculty as a result of participation in Hosting Organization’s educational program accredited through MPA and based on willful, wanton or negligent conduct on the part of the Hosting Organization and/or MPA. Intellectual property includes photos, images, media and video.
I, hereby, confirm all information as set forth above, as true and correct, and agree to deliver the activity as I have stated above in both a professional and educational matter. I also acknowledge and accept the compensation as outlined above as payment in full for my services. MPA reserves the right to withhold reimbursement should an activity lend itself to a biased nature. Changes or alterations to this agreement are not valid unless initialed by both parties. I further warrant and represent that this activity is my own original work, that I have the authority to enter into this agreement and that I am the sole copyright holder, or that I have obtained all necessary permissions or licenses from any persons or organizations whose material is included or used in my presentation.
Print Name(Required)
MM slash DD slash YYYY