Declaration of Conflict of Interest

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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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