All participating teams are required to have 5 team members and 1 team lead. Deadline to submit team form is Wednesday, November 20, 2019. Institution* Team Name* Team Leader InfoTeam Leader (Main Contact)* First Last Team Leader E-Mail*All information regarding The Match will be sent to this e-mail Specialty*neurosurgeryhead and neck surgeryradiation oncologyophthalmologyneurotologyotologyrhinologyotherOther Specialty:* Disclosures*If any disclosures, please indicate by selecting "yes" yes no Disclosure(s)*Please include the name of the company, what was received (salary, royalty, industry supported research, intellectual property rights, consulting fee, honoraria, ownership interest or other), and your role (employment, management position, independent contractor, consultant, speaking/teaching, advisory committee, review panel, board member, other).Name of CompanyWhat Was ReceivedRole Team Member 1Name* First Last E-mail* Specialty*neurosurgeryhead and neck surgeryradiation oncologyophthalmologyneurotologyotologyrhinologyotherOther Specialty:* Disclosures*If any disclosures, please indicate by selecting "yes" yes no Disclosure(s)*Please include the name of the company, what was received (salary, royalty, industry supported research, intellectual property rights, consulting fee, honoraria, ownership interest or other), and your role (employment, management position, independent contractor, consultant, speaking/teaching, advisory committee, review panel, board member, other).Name of CompanyWhat Was ReceivedRole Team Member 2Name* First Last E-mail* Specialty*neurosurgeryhead and neck surgeryradiation oncologyophthalmologyneurotologyotologyrhinologyotherOther Specialty:* Disclosures*If any disclosures, please indicate by selecting "yes" yes no Disclosure(s)*Please include the name of the company, what was received (salary, royalty, industry supported research, intellectual property rights, consulting fee, honoraria, ownership interest or other), and your role (employment, management position, independent contractor, consultant, speaking/teaching, advisory committee, review panel, board member, other).Name of CompanyWhat Was ReceivedRole Team Member 3Name* First Last E-mail* Specialty*neurosurgeryhead and neck surgeryradiation oncologyophthalmologyneurotologyotologyrhinologyotherOther Specialty:* Disclosures*If any disclosures, please indicate by selecting "yes" yes no Disclosure(s)*Please include the name of the company, what was received (salary, royalty, industry supported research, intellectual property rights, consulting fee, honoraria, ownership interest or other), and your role (employment, management position, independent contractor, consultant, speaking/teaching, advisory committee, review panel, board member, other).Name of CompanyWhat Was ReceivedRole Team Member 4Name* First Last E-mail* Specialty*neurosurgeryhead and neck surgeryradiation oncologyophthalmologyneurotologyotologyrhinologyotherOther Specialty:* Disclosures*If any disclosures, please indicate by selecting "yes" yes no Disclosure(s)*Please include the name of the company, what was received (salary, royalty, industry supported research, intellectual property rights, consulting fee, honoraria, ownership interest or other), and your role (employment, management position, independent contractor, consultant, speaking/teaching, advisory committee, review panel, board member, other).Name of CompanyWhat Was ReceivedRole Team Member 5Name* First Last E-mail* Specialty*neurosurgeryhead and neck surgeryradiation oncologyophthalmologyneurotologyotologyrhinologyotherOther Specialty:* Disclosures*If any disclosures, please indicate by selecting "yes" yes no Disclosure(s)*Please include the name of the company, what was received (salary, royalty, industry supported research, intellectual property rights, consulting fee, honoraria, ownership interest or other), and your role (employment, management position, independent contractor, consultant, speaking/teaching, advisory committee, review panel, board member, other).Name of CompanyWhat Was ReceivedRole
