(Form 3)
Conflict of Interest Self-Declaration Form for Officers
（Calculation period：
〜
）
For secretariat use only Receipt number：
Date of Receipt：
Month/Day/Year
To JSNM Chairperson of board of directors
Name
Institute/Department:
Position in JSNM：
JSNM Committee that you belong：
A. Checklist for self-declaration
1 Position as an officer, an advisor or an employee
of a company or an organization and the annual
remuneration from a single company or organization
of 1,000,000 yen or more
Applicable・Not applicable（Circle one）
（If applicable, record the following details for each
company or organization）
Name of a company or an organization：
Position(such as an officer, an advisor or an employee
executive, advisor or employee)：
2 Equity ownership in cases where profit from
equities of a single company during a one-year period
is 1,000,000 yen or more ,or where they own 5% or
more of the total equities
Amount of annual remuneration：
Applicable to either one or both・Not applicable to both
（Circle one）
（If applicable, record the following details for each
company）
Name of a company：
Number of share held：
Share price at the time of declaration（per share）：
Profit from the said share over the past year：
3 Patent royalties or licensing fees from companies
or organizations in cases where royalties or licensing
fees for a single patent are 1,000,000 yen or more per
year
4 Honoraria (such as lecture fees) paid by a
company or organization as compensation for the time
or labor of a researcher engaged for conference
attendance (presentation) and manuscript fees as
compensation for writing for a pamphlet or other
publication in cases where the annual sum of
honoraria and manuscript fees from a single company
or organization are 1,000,000 yen or more
5 Participation in clinical researches (clinical trials)
as a representative funded by companies and
organizations
Continued on page 2
Applicable・Not applicable（Circle one）
（If applicable, record the following details for each
patent）
Name of a company or organization：
Name of a patent：
Patent royalties or licensing fees：
Applicable・Not applicable（Circle one）
（If applicable, record the following details for company
or organization）
Name of a company or organization：
lecture and manuscript fees：
Applicable・Not applicable（Circle one）
（If applicable, record the following details for each
clinical research.）
Name of a company or organization：
Title of a clinical research：
1
6 Research fund (for entrusted researches,
collaborative researches, donations and so on) from
companies or organizations in cases where the annual
amount of research funding paid by a single company
or organization is 2,000,000 yen or more
7 Other remuneration (travel, gifts, or other in-kind
payments not directly related to research) in cases
where the annual remuneration received from a single
company or organization is 50,000 yen or more
Applicable・Not applicable（Circle one）
（If applicable, record the following details for each
clinical research.）
Name of a company or organization：
Amount of research fund：
Applicable・Not applicable(Circle one)
（If applicable, record the following details for each
company.）
Name of a company or organization：
Details of remuneration：
Amount of remuneration：
B. Checklist for the declarer’s spouse, relatives in the first degree, or any other persons who share
income or asset with the declarer
Name of an applicable individual (relation with the declarer)：
1 Position as an officer, an advisor or an employee of
a company or an organization and the annual
remuneration from a single company or organization of
1,000,000 yen or more
Applicable・Not applicable to both（Circle one）
（If applicable, record the following details for each
company or organization）
Name of a company or an organization：
Position(such as officer or advisor)：
Amount of annual remuneration：
2 Equity ownership in cases where profit from
equities of a single company during a one-year period
is 1,000,000 yen or more ,or where they own 5% or
more of the total equities
Applicable to either one or both・Not applicable to both
（Circle one）
（If applicable, record the following details for each
company））
Name of a company：
Number of shares held：
Share price at the time of declaration（per share）：
3 Patent royalties or licensing fees from companies or
organizations in cases where royalties or licensing fees
for a single patent are 1,000,000 yen or more per year
Profit from the concerned share over the past year：
Applicable・Not applicable（Circle one）
（If applicable, record the following details for each
patent））
Name of a company or organization：
Title of a patent：
Patent royalties or licensing fees：
Pledge： I hereby pledge as follows. The matters related to conflict of interest noted above are all true. I have no
other conflicts of interest than those noted above. I approve to disclose the contents of this form publicly and
legally, when requested.
Date
Month/Day/Year
Signature
2