Please disclose if you have any consulting arrangements, financial interests, corporate travel support, or other corporate relationships that could be perceived as a conflict of interest. You do not need to disclose specifics; only that the potential for conflict may exist. Note: Such arrangements do not necessarily disqualify an applicant but may lead to reassessment of assigned category of interest). If none, please so state.
Please identify the parent corporation and any subsidiaries of your company.
I (on behalf of myself and/or on behalf of the organization referenced above (“Affiliation”)) hereby represent and warrant that I (and/or, in the case of an entity (“Affiliation”), it) am/is a member of the American Dental Association Standards Committee on Dental Products, the ADA Standards Committee on Dental Informatics, their subcommittees or their working groups and/or the U.S. TAG or U.S. Sub-TAG for ISO/TC 106 Dentistry. These members may assist the American Dental Association (the “Association”) in the preparation of copyrightable materials (such materials, specifications, and all drafts thereof are hereinafter the “Materials”).
I acknowledge and agree, as an individual and on behalf of Affiliation, that the Association is the sole owner of all right, title and interest, including the entire exclusive copyright in and to the Materials, and has all rights to obtain copyrights for the Materials in its name. Further, I acknowledge and agree, as an individual and on behalf of Affiliation, that neither I nor Affiliation has any ownership rights in the Materials. I represent and warrant that: (1) he/she has full power and authority to enter into this Agreement (as an individual and on behalf of Affiliation) and to grant any and all rights, interest and title granted herein; (2) except for material in the public domain, any and all contributions made by the undersigned to the Materials are original to the undersigned or the undersigned has obtained full permission from the copyright owner for use in the Materials. The undersigned hereby assigns any and all ownership rights the undersigned or Affiliation may have in the Materials to the Association. The undersigned further agrees that he/she will execute any additional documents necessary or appropriate to effect this assignment to the Association, upon request.*