OFFICE USE
APPLICATION FORM
23rd Annual Meeting of JSGCT 2017
Please carefully fill in this form and send back with your abstract as attachment in MS Word format to the email address:
Last Name: / First: / Middle: / Degrees:
Affiliated Institution:
Address:
City: / State:
Zip: / Country: / DOB (DD/MM/YY):
Phone Number / ( / ) / Fax Number
E-mail address:
Title of abstract:
Please choose abstract categories (one or several):
A. Basic science and technologies
A1. Gene regulation
A2. Genome editing
A3. Oligonucleotides
A4. RNAi technologies and miRNA
A5. Stem cells (include ES cells and iPS cells)
A6. Tissue engineering
A7. Cell processing
A8. Bioimaging
A9. Immune/Inflammation regulation
A10. Others
B. Vector development and gene transfer technologies
B1. Viral vectors
B2. Non-viral vectors
B3. Other gene transfer technologies / C. Preclinical studies for gene and cell therapy
(include studies for molecular pathogenesis)
C1. Genetic diseases
C2. Cancer
C3. Cardiovascular diseases
C4. Neurologic, ophthalmic, and musculo-skeletal diseases
C5. Infectious diseases and vaccines
C6. Cell therapy
C7. Regenerative medicine
C8. Others
D. Clinical studies for gene and cell therapy
D1. Genetic diseases
D2. Cancer
D3. Cardiovascular diseases
D4. Neurologic, ophthalmic, and musculo-skeletal diseases
D5. Infectious diseases and vaccines
D6. Cell therapy
D7. Others
Presentation Format (Please note that there may be cases that we cannot meet your request.)
1) Select your presentation format: / Oral / Poster / Either
2) For authors who selected Oral Presentation:
I prefer to make my presentation in English / Yes
Disclosure of Relevant Conflict of Interest (COI) in connection with the above mentioned presentation
for all authors (including co-authors)
No, we do not have any COI with any company and/or organization.
Yes, we have COI with the following company(ies) and/or organization(s) listed below.
If yes, please precisely complete the list below on all of authors (including co-authors)

23rd Annual Meeting of Japan Society of Gene and Cell Therapy

Conflict of Interest Disclosure statement by author

Name of Author
Title of Presentation

In connection with the above-mentioned presentation, report the names of any companies and organizations and state

the Conflict of Interest for each entry.

*Any COI during the past 12 months should be disclosed at the time of abstract submission.

Entry / Status / If yes, provide the name of the company
and /or organization
1.  Postemployment/leadership
position/advisory role in companies or profit-oriented organizations, and
compensation related to the post.
(More than one million yen per year from one company/organization) / Self:
Yes / No
Family:
Yes / No
2.  Stock ownership and profits from stock ownership.
(More than one million yen per or 5% per year from one company/organization) / Self:
Yes / No
Family:
Yes / No
3.  Patent royalties/licensing fees paid by companies and profit-oriented
organizations.
(More than one million yen per patent per year) / Self:
Yes / No
Family:
Yes / No
4.  Honoraria (e.g. lecture fees) paid by
companies and profit-oriented
organizations to compensate for
attendance (presentation) at
meeting/s.
(More than one million yen in total per year from one company/organization) / Self:
Yes / No
5.  Manuscript fees paid by companies and profit-oriented organizations for writing promotional material (e.g. brochures)
(More than one million yen in total per year from one company/organization) / Self:
Yes / No
6.  Research funding (clinical trial, sponsored or funded research, collaborative research etc.) provided by companies and profit-oriented organizations.
(More than one million yen in total per year from one company/organization) / Self:
Yes / No
7.  Scholarship contributions from companies and profit-oriented
organizations.
(More than two million yen in total per year from one company/organization) / Self:
Yes / No
8.  Study group sponsorship by companies and profit-oriented organizations.
(The researcher belongs to study group) / Self:
Yes / No
9.  Payments from companies and profit-oriented organizations for anything unrelated to research, education, or medical practice.
(More than fifty thousand yen in total per year from one company/organization) / Self:
Yes / No

*Report on the lead presenter him/herself, his/her spouse, first-degree relatives, and anyone who shares his/her

income and wealth.

NOTE 1: This COI Disclosure Statement will be kept on file for 5 years after the meeting presentation.

However, any statements relating to rejected presentations will be destroyed immediately and will not be returned to

the presenter.

NOTE 2: The COI of authors must be appropriately managed by his/her academic institutions COI committee.

If not, please take appropriate steps at your own institution by the time of abstract submission

s

Date of disclosure: