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Declaration of Conflict of Interest

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Enter the full name of the organisation (such as the company or other organisation) for which this declaration of conflict of interest is being used. This organisation will be referred to as the "organisation" in subsequent questions.

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CONFLICT OF INTEREST DECLARATION

________ (ACN..............................................) ("Organisation")


STAFF MEMBER DETAILS

Name: ________

Job title/position: ________

Email: ________

Phone: ________


DECLARATION

I, ________ of ________, hereby declare that to the best of my knowledge the following is true and correct, except as disclosed in this form:

  • I do not have any actual, potential, or perceived personal interest in any matters related to my role with ________ which could affect my ability to act impartially in the best interests of ________.
  • I do not have any friends, family members, business partners or other acquaintances who have a personal interest in any matters related to my role with ________ which could affect my ability to act impartially in the best interests of ________.
  • I do not have any actual, potential, or perceived personal interest in any matters related to my role with ________ which could affect my ability to act honestly and impartially, to fulfil my duties and perform my role with ________ in accordance with community expectations and Australian law.
  • I do not have any actual, potential, or perceived personal interest in any matters related to my role with ________ which could be considered by a reasonable person to potentially affect my ability to perform or to act honestly and impartially, to fulfil my duties and perform my role with ________ in accordance with community standards and Australian law.

Notwithstanding the foregoing, I hereby disclose the following actual, potential or perceived conflict(s) of interest:

________

I warrant and agree that:

  • I have carefully reviewed this form and I confirm that the information I have provided in this form is true, correct, and complete to the best of my knowledge.
  • I will immediately notify ________ if there are any changes in my circumstances which affect in any way the truth, correctness or completeness of the information provided in this form.
  • 5 8888 82225852282 222822 ________ 82 522 5558282258 822288828 22 82225282 55882 52225 5 5582 858282225 2588 2252.
  • 5 8888 228828 522 5852828228 22 ________ 82 52852822 22 252 2525222222 25 2828252822 22 522 22 22 822288828 22 82225282.
  • 5 5252582525 2552 252885822 25882 25 2888255822 82225252822 82 2588 2252 88 5 85828258 offence.


    Signed by ________: ............................................................

    Date: ________

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CONFLICT OF INTEREST DECLARATION

________ (ACN..............................................) ("Organisation")


STAFF MEMBER DETAILS

Name: ________

Job title/position: ________

Email: ________

Phone: ________


DECLARATION

I, ________ of ________, hereby declare that to the best of my knowledge the following is true and correct, except as disclosed in this form:

  • I do not have any actual, potential, or perceived personal interest in any matters related to my role with ________ which could affect my ability to act impartially in the best interests of ________.
  • I do not have any friends, family members, business partners or other acquaintances who have a personal interest in any matters related to my role with ________ which could affect my ability to act impartially in the best interests of ________.
  • I do not have any actual, potential, or perceived personal interest in any matters related to my role with ________ which could affect my ability to act honestly and impartially, to fulfil my duties and perform my role with ________ in accordance with community expectations and Australian law.
  • I do not have any actual, potential, or perceived personal interest in any matters related to my role with ________ which could be considered by a reasonable person to potentially affect my ability to perform or to act honestly and impartially, to fulfil my duties and perform my role with ________ in accordance with community standards and Australian law.

Notwithstanding the foregoing, I hereby disclose the following actual, potential or perceived conflict(s) of interest:

________

I warrant and agree that:

  • I have carefully reviewed this form and I confirm that the information I have provided in this form is true, correct, and complete to the best of my knowledge.
  • I will immediately notify ________ if there are any changes in my circumstances which affect in any way the truth, correctness or completeness of the information provided in this form.
  • 5 8888 82225852282 222822 ________ 82 522 5558282258 822288828 22 82225282 55882 52225 5 5582 858282225 2588 2252.
  • 5 8888 228828 522 5852828228 22 ________ 82 52852822 22 252 2525222222 25 2828252822 22 522 22 22 822288828 22 82225282.
  • 5 5252582525 2552 252885822 25882 25 2888255822 82225252822 82 2588 2252 88 5 85828258 offence.


    Signed by ________: ............................................................

    Date: ________

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