Extract to table

Each investigator must complete and return this form to the Sponsor prior to site activation and first patient enrollment

Investigators who hold stock, stock options, warrants, or other equity instruments in Penterra, or whose spouses or dependent children hold such interests, must carefully evaluate whether these interests trigger the disclosure requirements set forth in this form

Lakemont Medical Center, Site 008), this form must be completed and submitted to the Sponsor prior to site activation

SECTION 4: FINANCIAL INTEREST CERTIFICATION — PART A (Certification of No Disclosable Financial Interests) INSTRUCTIONS: This section permits the investigator to certify that he or she does not have any of the financial interests or arrangements that must be disclosed under 21 C

To complete Part A, the investigator must be able to truthfully check each of the four boxes below (Sections 4

If the investigator is unable to check even one of the four boxes, the investigator must not sign Part A and must instead complete Part B (Section 5) of this form, providing full disclosure of the relevant financial interest(s)