Conflict of Interest Declaration Form

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What is the reason for using this Conflict of Interest Declaration Form?

The employee wishes to disclose a conflict of interest situation

The employee wants to certify they are not aware of any conflict of interest situation

A conflict of interest happens when an employee has a personal interest that could make it hard for them to be fair in their employer's business decisions. For instance, if their employer wants to hire an accountant, and the accountant is the employee's husband or wife, that can create a conflict of interest. Please note that this form will be used in two cases. In the first case, it is used to share the employee's actual or potential conflict of interest. On the other hand, this form can be used to show that the employee does not have any conflict of interest. If the employee would like to share information about particular instances where there might be a conflict of interest, click "The employee wishes to disclose a conflict of interest situation". However, if the employee is not involved in any conflict of interest, click "The employee wants to certify they are not aware of any conflict of interest situation". If this second option is chosen, it means that the employee is using this form to disclose no conflict of interest exists.

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________ (the "Company")

CONFLICT OF INTEREST DECLARATION FORM

Name of employee: ________

Job title/position: ________

Email: ________

Phone: ________

DECLARATION

I, ________, of ________, do hereby declare and undertake as follows:

That I do not have an actual, financial, or other personal interest in any matter relating to my position in this Company which can affect my commitment and loyalty to this Company.

That I will not engage in any transaction that will cause a potential conflict of interest or financial interest or potential gain in the transaction of the Company.
That I shall not be involved in the recruitment, promotion, or appointment of a close relative without disclosing such matter to management.
That I will not engage in a transaction or activity that conflicts with the interests or objectives of this Company.
That I will not use or misappropriate the Company's confidential or trade secret information for personal gain or benefit.
That I will not operate, manage, or otherwise be involved in a business that directly competes with the business of the Company.

That I will not accept a substantial monetary or other gift and not disclose it to the Company.

Notwithstanding the above, the aforementioned declaration, I hereby disclose the following actual or potential conflict of interest:

________

I undertake not to let my actions or interest be impeded by any personal gain or benefit.

I undertake to avoid any future transaction, dealings, or relationship that may prejudice my fiduciary duties or commitment to the Company.

ACKNOWLEDGEMENT

I acknowledge that I have carefully reviewed this form and I confirm that the information provided herein is true, correct, and complete to the best of my knowledge.

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Name of Employee:......................................................................................

Date of Receipt:............................................................................................

Signature of Employee:................................................................................

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