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Conflict of Interest Declaration - Sample

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Conflict of Interest Declaration - Sample

This is a sample form to help you get started making one for your organisation.

This form is for all Board Members to complete [following the AGM], and at any time when a new Conflict of Interest is identified. Please see the Conflict of Interest Policy for full details.

Name:

 

Position:

 

Declaration:

Please cirle:

I declare that I do not have any interests which might give rise to a real or perceived conflict of interest.

OR

I declare that I do have interests which might give rise to a real or perceived conflict of interest.

Describe the nature of the interest:

(eg financial, other directorships, familial, memberships of other organisations)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

By signing the below, I agree that I have read and understood the requirements set out in the Conflict of Interest Policy and I have made a full and frank disclosure of all matters that may put me in a conflict of interest situation in performing my role in relation to the TasCOSS Board. I acknowledge that non-discloser could result in action being taken to terminate my work with the Board.

Signature:

 

Date:

 

Completed forms are forwarded to the EA to CEO.