II ASTRAZENECA
FOUNDATION
COMPETITION
V IN4MED
CARINA CASTRO SILVA
NUNO MENDES
DIOGO MATOS
GONÇALO COSTA
Núcleo de Estudantes de Medicina da Associação Académica de Coimbra
Pólo das Ciências da Saúde, Unidade Central Piso -1,
Azinhaga de Santa Comba, Celas, 3000-548 Coimbra
nemaac.net
facebook.com/nem.academica [email protected]
II AstraZeneca Foundation
Competition
V In4Med
ANNEX
TERM OF RESPONSIBILITY
I, _______________________________________, holder of the identification document nr.
_____________________________, issued in ___________________, on ____/____/____, OR
valid until ____/____/____, commit to comply with the full extent of the Rules and
Regulation of the II AstraZeneca Foundation Competition and to be present at
the V In4Med.
(Candidate’s signature)
_________________, _____ of _________________ 2015
Núcleo de Estudantes de Medicina da Associação Académica de Coimbra
Pólo das Ciências da Saúde, Unidade Central Piso -1,
Azinhaga de Santa Comba, Celas, 3000-548 Coimbra
nemaac.net
facebook.com/nem.academica
[email protected]
2
II AstraZeneca Foundation
Competition
V In4Med
DECLARATION OF CONFLICTING INTERESTS
I, ___________________________________________, holder of the identification document
nr. _____________________________, issued in ___________________, on ____/____/____, OR
valid until ____/____/____, would like to declare the following existing/potencial
conflict of interest situation arising from my participation at the II AstraZeneca
Foundation Competition, at the V In4Med.
a) Person with whom I have oficial dealings and/or private interests
_____________________________________________________________________________________
_________________________________________________________
b) Brief description of my duties which involve the person mentioned
_____________________________________________________________________
_____________________________________________________________________
(Candidate’s signature)
_________________, _____ of _________________ 2015
Núcleo de Estudantes de Medicina da Associação Académica de Coimbra
Pólo das Ciências da Saúde, Unidade Central Piso -1,
Azinhaga de Santa Comba, Celas, 3000-548 Coimbra
nemaac.net
facebook.com/nem.academica
[email protected]
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II AstraZeneca Foundation
Competition
V In4Med
INFORMED CONSENT
I, ___________________________________, holder of the identification document
nr.___________________, issued in ___________________, on ____/____/____ OR valid until
____/____/____ , declare that I have read the Rules and Regulation of the II
AstraZeneca Foundation Competition and I hereby authorise my colleague /
student
______________________________________,
holder
of
the
identification
document nr. _________________________, issued in ___________________, on the
____/____/____, to present the project ______________________________ at the II
AstraZeneca Foundation Competition.
(Co-author’s signature)
__________________, ___ of _________________ 2015
Núcleo de Estudantes de Medicina da Associação Académica de Coimbra
Pólo das Ciências da Saúde, Unidade Central Piso -1,
Azinhaga de Santa Comba, Celas, 3000-548 Coimbra
nemaac.net
facebook.com/nem.academica
[email protected]
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