OFFICE USE ONLY

Form 2 (English version)

Receipt No.

Receipt date (MM/DD/YYYY)

The Japanese Association for Molecular Target Therapy of Cancer
Conflict of Interest (COI) Disclosure Form（for Lead Presenters at Annual Meetings, Workshops, and other conferences）
Period to disclose is within the past THREE years from the date of disclosure.
If you need more space of the entry columns, please copy this form or attach separate pieces of paper.
To President, The Japanese Association for Molecular Target Therapy of Cancer,

Name of the Lead Presenter:
Membership number (if applicable):Affiliation and Position:
Part A. Lead Presenter
Categories(1) Annual value of remuneration as anofficer or an advisor (includingconsultant, etc.) received from a single
company or for-profit organization
related to your presentation is 1 million
yen or more

Check appropriate boxes

☐ Yes

☐ No

If Yes, please fill in the column below with respect to each company
and each year.
Name of company/organization:

Role:
Remuneration:(1) 1-5 million yen, (2) 5-10 million yen, (3) more than 10 million yen
Example: X company; scientific advisor; 2015 (1), 2016 (2)(2) Annual profit from shares of a single ☐ Yes☐ Nocompany related to your presentation is
1 million yen or more, or the proportion If Yes, please fill in the column below with respect to each companyof shares owned in the company is 5%
and each year.
or moreName of company:
Proportion of shares owned (%):
Annual profit from shares:(1) 1-5 million yen, (2) 5-10 million yen, (3) more than 10 million yen
Example: Y Industry; 8%; 2015 none, 2016 (2)1(3) Annual value of patent royalties
received from a single company or forprofit organization related to yourpresentation is 1 million yen or more☐ Yes☐ No

If Yes, please fill in the column below with respect to each company
and each year.
Name of company/organization:

Patent royalties:(1) 1-5 million yen, (2) 5-10 million yen, (3) more than 10 million yen
Example: Z Pharmaceutical; 2015 (2), 2016 (1)(4) Total annual value of honoraria(lecture fees or fees for chairperson)
received from a single company or forprofit organization related to yourpresentation is 500,000 yen or more☐ Yes☐ No

If Yes, please fill in the column below with respect to each company
and each year.
Name of company/organization:

Lecture fees or fees for chairperson:(1) 0.5-1 million yen, (2) 1-2 million yen, (3) more than 2 million yen
Example: A Company; 2015 (1), 2016 (1)(5) Total annual value of manuscript
fees received from a single company or
for-profit organization related to yourpresentation is 500,000 yen or more

☐ Yes

☐ No

If Yes, please fill in the column below with respect to each company
and each year.
Name of company/organization:

Manuscript fee:
(1) 0.5-1 million yen, (2) 1-2 million yen, (3) more than 2 million yen
Example: B Industry; 2015 (1), 2016 None

(6) Total annual value of research funds(including joint research funds,
contract research funds, clinical trialsetc.) received from a single company or
for-profit organization related to yourpresentation is 1 million yen or more☐ Yes☐ No

If Yes, please fill in the column below with respect to each case,each company and each year.
Name of company/organization:

Research fund:(1) 1-10 million yen, (2) 10-20 million yen, (3) more than 20 million yen
Example: C Company; 2015 (1), 2016 (2)(7) Total annual value ofscholarship/incentive endowments
received from a single company or forprofit organization or research grants

☐ Yes

☐ No

If Yes, please fill in the column below with respect to each case,each company and each year.

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provided directly from a private
academic support organization related
to your presentation is 1 million yen ormore

Name of company/organization:

Research fund:(1) 1-5 million yen, (2) 5-10 million yen, (3) more than 10 million yen
Example: D Company; 2015 (1), 2016 (2)(8) Endowed course provided by acompany, etc. (Enter if the applicant
belongs to an endowed course, etc.)☐ Yes☐ No

If Yes, please fill in the column below with respect to each company
and each year.
Name of company/organization:

Name of endowed course(9) Annual remuneration (travel
expenses, gifts, etc. that are notdirectly related to research) received
from a single company or for-profit
organization related to yourpresentation is 50,000 yen or more☐ Yes☐ NoIf Yes, please fill in the column below with respect to each company
and each year.
Name of company/organization:

Substance of remuneration:

Value:(1) 50,000-200,000 yen, (2) more than 200,000 yen

Part B. Lead Presenter’s spouse, first-degree family and those who share the income and property**Lead Presenter needs to complete this part only if his/her spouse, first-degree family, or those who share the income andproperty has any COI to disclose. If none of them have COI to disclose, Lead Presenter does NOT need to complete this part.

Name of person(s) concerned:
Relationship with Lead Presenter:

Categories(1) Annual value of remuneration as anofficer or an advisor (includingconsultant, etc.) received from a single
company or for-profit organization
related to Lead Presenter’spresentation is 1 million yen or more

Check appropriate boxes

☐ Yes

☐ No

If Yes, please fill in the column below with respect to each company
and each year.
Name of company/organization:3

Role:
Remuneration:(1) 1-5 million yen, (2) 5-10 million yen, (3) more than 10 million yen
Example: X company; scientific advisor; 2015 (1), 2016 (2)(2) Annual profit from shares of a single ☐ Yes☐ Nocompany related to Lead Presenter’spresentation is 1 million yen or more, or If Yes, please fill in the column below with respect to each company
the proportion of shares owned in theand each year.
company is 5% or more
Name of company:
Proportion of shares owned (%):
Annual profit from shares:(1) 1-5 million yen, (2) 5-10 million yen, (3) more than 10 million yen
Example: Y Industry; 8%; 2015 none, 2016 (2)(3) Annual value of patent royalties☐ Yes☐ No
received from a single company or forIf Yes, please fill in the column below with respect to each company
profit organization related to Lead
Presenter’s presentation is 1 million yen and each year.
or moreName of company/organization:

Patent royalties:(1) 1-5 million yen, (2) 5-10 million yen, (3) more than 10 million yen
Example: Z Pharmaceutical; 2015 (2), 2016 (1)I confirm that the information reported above is accurate, and I do not have any other COI with company orfor-profit organization related to my presentation. If there is a request from social or moral point of view, I
understand that the information reported above may be disclosed publicly at the discretion of Board ofDirectors of the Japanese Association for Molecular Target Therapy of Cancer.

Signature of Lead Presenter:
Date (MM/DD/YYYY):

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