Financial Disclosure

* Indicates a Required Field

1.) Please select your activity / role in NYSCENA:*

Other activity/role not listed above:

2.) Is there an actual, potential, or perceived Financial Disclosure for yourself or spouse/partner? *

3.) Please indicate the relationship for that actual, potential, or perceived Financial Disclosure.
Check any that apply:

Salary

Royalty / Stock

Speakers Bureau

Consultant

Other

Other relationship for Financial Disclosure not listed above:

List name of commercial entity and relationship:*

Statement of Compliance:

I attest that:

I have read the New York State ENA Financial Disclosure Policy before completing this Disclosure Statement. (Click here to read it.)
I understand that the terms "family relationship" and "immediate family" as used in reference to a Financial Disclosure, refer to any parent, spouse, domestic partner, or child.
I attest that I will notify NYSCENA if there are any changes to the above or relevant relationships within the next 12 Months.

Name:*

Email Address:*

Date:*

By pressing submit below, I attest that the typed signature above represents my signature.