Committee Applications

I. Personal Information

Name: *

Please type your full name.

Email Address: *

Invalid email address (make sure there are NO spaces)

Country: *

Please type your institution.

II. Apply

Find the committee tasks & descriptions here

Insert check:

Awards CommitteeConflict of Interest Oversight CommitteeMembership CommitteeImage Library Committee Invalid Input

A brief background about yourself and reasons why you would like to join: *

Please include your personal statement.

III. Committee Policy

A single term is defined as duration of time in between two (2) consecutive WCBIP closing ceremonies. Therefore a term is approximately 2 years.
Every committee member shall serve a maximum of two terms (approx. 4 years), except for committee chairs & past-chairs who shall serve more terms on committee in their leadership positions.
Every committee chair must complete one (1) full term as chair.
Immediately after term as Chair, he or she shall serve an additional term as past-chair of the committee to ensure continuity and to provide guidance to the new chair and members.
After past-chair term ends, tenure in the committee shall end regardless of number of terms served as a general committee member or otherwise.
Service on a committee, special section or taskforce presumes the person will do their very best to attend the WCBIP World Congress.
It is the responsibility of the committee chair to contact by teleconferencing and email all members of his/her committee in order to get to know all committee members.

IV. Conflict of Interest Policy, Rules and Disclosure

Read the complete Conflict of Interest Policy and Rules document here.

Disclosure

Your disclosures below. The WABIP COI oversight committee will evaluate your answers as it pertains to our Conflict of Interest Policy and Rules.

1) Currently have full or part time employment, leadership, board member (in a non-WABIP member society), or advisory position in a commercial or nonprofit entity? *

NoYes Must choose one.

If “Yes” please state the name of the entity and your specific role including dates of engagement and expected term of office or engagement:

Please type details.

2) Currently receive royalties or other benefits (travel, accommodations, honoraria, gifts) from a commercial or nonprofit entity? *

NoYes Must choose one.

If “Yes” please state the name of the entity and the type of royalty or benefit:

Please type details.

3) Currently obligated to provide expert testimony or other legal assistance on behalf of a commercial or nonprofit entity? *

NoYes Must choose one.

If “Yes” please state the name of the entity:

Please type details.

4) Currently involved with research funding or grant support (regardless whether payment is made to individuals or institutions) by a commercial or nonprofit entity? *

NoYes Must choose one.

If “Yes” please state the name of the entity and indicate the level of support. Without disclosing proprietary information, please give a brief description of the research goals:

Please type details.

5) Will receive honoraria for speaking engagements, presentations, or other services if paid directly to the individual by a commercial or nonprofit entity? *

NoYes Must choose one.

If “Yes” please state the name of the entity, when the presentations or services are to be provided, and the general subject of presentations or services:

Please type details.

6) Currently own patent rights or patents pending? *

NoYes Invalid Input

If “Yes” please provide patent numbers and a description of any existing patents. For pending patents please provide a general area of clinical medicine to which the patent may be pertinent (i.e. genomic analysis, diagnostic endoscopy, etc) without disclosing specific details which may compromise the integrity of the patent application.

Please type details.

7) Currently own stocks or stock options in a privately or publically held start-up, technology or pharmaceutical company? *

NoYes Must choose one.

If “Yes” please state the name(s) of the companies or corporations from which you currently own stock or stock options:

Please type details.

Please list additional comments, conflict of interest and disclosures here if necessary:

Invalid Input

V. Agreement

By providing my signature below, I hereby confirm and declare the following:

I shall fully comply with the Conflict of Interest Policy and Rules (Article IV).
All information that I have submitted and disclosed to the WABIP in this Application is, to the best of my knowledge, true, accurate, and complete.
I have read and understood the entirety of this Application (Articles I – V).

Signature: *

Please type your signature.

Click: *

Invalid Input

I. Personal Information

II. Apply

III. Committee Policy

IV. Conflict of Interest Policy, Rules and Disclosure

V. Agreement

About Us

Upcoming Events

Latest News

Member Societies

Newsletter

Sections

FAQ

View

CONTACT US

Write

LOG IN

Access

About WABIP

Quick Links

Subscribe

Contact Us

Search this site