To conduct, sponsor or supply pertinent mandatory educational seminars. In order to be considered complete, every question on the application must be answered. If you require more space, please use additional pages and attach them to the application. Information provided is confidential. Complete clinical details and settlement amounts are required on all cases regardless of status or date of occurrence.
Current information is required.
If more than one case, photocopy this form for each case. All information will be kept in the strictest confidence. Without our written consent in advance, you will not disclose to third parties any Confidential Information or to make use of any such information directly or indirectly other than in connection with our business and affairs. This agreement applies both during your active participation in our society and after you cease active participation. All written, printed, photographic, electronically recorded and other documents and data relating directly or indirectly to any information made or compiled by, or delivered or made available to, or otherwise obtained by you are exclusive property.