Conflict of Interest Self-Declaration Form for Officers (effective for 1 year before inauguration: 201x.01.01 - 201x.12.31)

Declaration of conflict of interest (COI) should be limited to persons involved in a business, corporate organization, or other for-profit group related to activities of the Japanese Society of Periodontology

to Chair of non-profit organization, Japanese Society of Periodontology

Name of Declarer (Member No.):（）

Affiliated Institution (organization/Department/specialty), Occupation:

Title in this Society:□President □ Director □ Auditor □Person responsible for scientific meetings, lectures open to the public, lecture meetings, or similar events □ Chairperson of each committee □Member of each committee□ Member of working committee, others

Name of committee: / [ / committee] / [ / committee]
*Fill in all if you belong to multiple committees / [ / committee] / [ / committee]

A. Matters to be declared by declarer

1. Assumption of the position of officer, advisor, or employee, at a business, organization, or group, and reward if any

(□ Yes/□ No)

(Fill in if you earn ≥1 million yen per year from a single business, organization, or group)

Name of businessor group / Title (e.g., officer, advisor) / Classification of acquisition amount
1
2
3

Classification of acquisition amount: (1) ≥ 1 million yen - < 5 million yen (2) ≥ 5 million yen

2. Holding stocksor bonds and receivingbenefit from them (benefits obtained in the last year)

(□ Yes/□ No)

(Fill in if you earn ≥1 million yen annual dividends from a single business or you own ≥5% of all shares of the business)

Name of business / No. of shares held / Price of one stock at time of declaration / Classification of acquisition amount
1
2

Classification of acquisition amount: (1) ≥ 1 million yen - < 5 million yen (2) ≥ 5 million yen

3. Royalties from patents or other sources from a business, organization, or group(□ Yes/□ No)

(Fill in if the annual income of one patent is ≥1 million yen)

Name of business or group / Patent / Classification of acquisition amount
1
2

Classification of acquisition amount: (1) ≥ 1 million yen - < 5 million yen (2) ≥ 5 million yen

4. Perdiem compensation (lecture fees, etc.) paid from a business, organization, or group for the time and labor taken up by attendance (presentation) at a meeting(□ Yes / □ No)

(Fill in if the annual income or honorarium paid by a single business, organization, or group is≥0.5 million yen in total)

Name of business or group / Classification of acquisition amount
1
2
3
4
5
6
7
8
9
10

Classification of acquisition amount: (1) ≥0.5 million yen - <2 million yen (2) ≥2 million y

5. Manuscript fees paid by a business, organization, or group for the authoring of pamphlets, website, or similar materials

(□ Yes/□ No)

(Fill in if the annual income paid by a single business organization, or group as manuscript fees is ≥0.5 million yen in total)

Name of business or group / Classification of acquisition amount
1
2

Classification of acquisition amount: (1) ≥ 0.5 million yen - < 2 million yen (2) ≥ 2 million yen

6. Dental research fees provided by a business, organization, or group(□ Yes/□ No)

(Fill in if you earn total annuals fees for dental research (clinical trial fees, clinical research fees, contractresearch, joint research, scholarship donations, etc.) paid by a single business, organization, or group of ≥1 million yen)

Name of business or group / Classification of research fee / Classification of acquisition amount
1
2
3

Classification of research fee: (1) clinical trial, (2) industry-university joint research, (3) contract research

Classification of acquisition amount: (1) ≥1 million yen - <5 million yen, (2) ≥5 million yen

7. Taking part or serving concurrently in an endowed lecture sponsored by a business, organization, or group

(□ Yes/□ No)

Name of business or group / Name of course / Duration
1
2

8. Receipt of travel expenses or other giftsnot directly related to the research, provided by a business, organization, or group

(□ Yes/□ No)

(Fill in if the total annual amountis ≥ 50 thousand yen from a singlebusiness, organization, or group)

Name of business or group / Contents of the reward / Classification of acquisition amount
1
2
3

Classification of acquisition amount: (1) ≥50 thousand yen - <0.2 millionyen (2) ≥0.2 millionyen

B. Declaration for Declarer’s spouse, first-degree family members and persons with whom expenses are shared

Tick the applicablebox □

□ No declarations: You donot need to answer the following questions

□ Yes, I/we have something to declare: Fill in the following form as applicable. If there is nothing to declare, tick the box indicating“No”

1. Assumption of the position of officer, advisor, or employee, at a business, organization, or group, and reward if any

(□ Yes/□ No)

(Fill in if you earn ≥1 million yen per year from a single business, organization, or group)

Name / Relationship with Declarant
Name of business or group / Title (e.g., officer, advisor) / Classification of acquisition amount
1
2
3

Classification of acquisition amount: (1) ≥ 1 million yen - < 5 million yen (2) ≥ 5 million yen

2. Holding stocks or bonds and receivingbenefit from them (benefits obtained in the last year)

(□ Yes/□ No)

(Fill in if you earn ≥1 million yen annual dividends from a single business or you own ≥5% of all shares of the business)

Name / Relationship with Declarant
Name of business / No. of shares held / Price of one stock at time of declaration / Classification of acquisition amount
1
2

Classification of acquisition amount: (1) ≥ 1 million yen - < 5 million yen (2) ≥ 5 million yen

3. Royalties from patents or other sources from a business, organization, or group(□ Yes/□ No)

(Fill in if the annual income of one patent is ≥1 million yen)

Name / Relationship with Declarant
Name of business or group / Patent / Classification of acquisition amount
1
2

Classification of acquisition amount: (1) ≥ 1 million yen - < 5 million yen (2) ≥ 5 million yen

Pledge: The above conflict of interestsare true and correct. There are no other conflict of interests that may interfere with my job performance in the Japanese Society of Periodontology. I accept that the contents of this report can be disclosedif there are social and/or legal requests.

Date of declaration:MM DD YYYY

Signatureseal

(This COI declaration will be kept for two years after the term or withdrawalfrom office)

Receipt No.

Please use this page if you need more space for your declaration(Attachment)

Name of Declarer:

<Contents of declaration

1. Assumption of the position of officer, advisor, or employee, at a business, organization, or group, and reward if any

2. Holding stocks or bonds and receivingbenefit from them (benefits obtained in the last year)

3. Royalties from patents or other sources from a business, organization, or group

4. Per diem compensation (lecture fees, etc.) paid from a business, organization, or group for the time and labor taken up by attendance (presentation) at a meeting

5. Manuscript fees paid by a business, organization, or group for the authoring of pamphlets, website, or similar materials

6. Dental research fees provided by a business, organization, or group

7. Taking part or serving concurrently in an endowed lecture sponsored by a business, organization, or group

8. Receipt of travel expenses or other gifts not directly related to the research, provided by a business, organization, or group

Declarer
(A・B) / Declaration No. / Name of a business, organization, or group / Application (title, patent name, type of grant)
*As for (2), No. of shares held and stock price / Classification of acquisition amount (see the applicable section)

*If more space isneeded, make a copy of the form