To ensure the scientific objectivity of articles appearing in the Asian Spine Journal, the Journal requires that all authors disclose all potential or perceived conflicts of interest that may exist.

Manuscript title:  _________________________________________________________________________________
Name of Author:  _______________________________________  Signature:  _________________________________

As the corresponding author, I declare the following informations regarding the specific conflict of interests of authors of our manuscript aforementioned.

Examples of Conflict of Interest: Source of Funding, Paid consultant to Sponsor, Study Investigator Funded by Sponsor, Employee of Sponsor, Board membership with Sponsor, Stock Holder for Mentioned Product, Patent Inventor for Mentioned Product, Any Financial Relationship to Competitors of Mentioned Product, and others (please specify)

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Source of funding:

I accept the responsibility for the completion of this document and attest to its validity on behalf of all co-authors.
Corresponding author (name/signature):  _________________________  _________________________
Date:  _________________________

Please post or fax the completed form to Asian Spine Journal; Department of Orthopedic Surgery, Uijeongbu St. Mary's Hospital, 65-1 Geumo-dong, Uijeongbu-si 480-717, Gyeonggi-do, the Republic of Korea.   Tel +82-31-820-3578  Fax +82-31-847-36718  E-mail spinepjb@catholic.ac.kr