As the scientific director of the CME/CPD programme “name of the programme” taking place in “city, country” on “date” I declare that:

• The scientific programme of the course was developed under my supervision and responsibility, that it is scientifically balanced and without bias;

• All faculty and other speakers at this scientific event are aware of, and have agreed, to sign the EORNA ACE disclosure form, and have disclosed any potential conflict of interest that they may have. This must be stated at the beginning of the presentation and in all printed material;

• I am aware of the source and form of any commercial funding received to develop this programme;

• My signature appears on each EORNA ACE Certificate distributed to all participants to this educational programme;

• I am aware of the type of evaluation form participants will have to complete at the end of the programme (EORNA ACE evaluation form or other) and agree to provide the necessary feed-back to EORNA ACE;

• All printed material related to the above-mentioned programme does bear the EORNA ACE logo (or EORNA Logo with mention “Approved by EORNA Accreditation Council for Education) and accreditation statement.

• I accept responsibility for the payment of all fees to EORNA ACE in connection with this application.

Printed title and name of the course director

Signature: …………………………. (Electronic Signature)

Date:

The signed original should be sent to the EORNA ACE + address.

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