Conflict of Interest Declaration

Part A: Personal Details

• Name: [FULL NAME]
• Position/Title: [JOB TITLE]
• Department: [DEPARTMENT]
• Date: [DD/MM/YYYY]

Part B: Conflict Disclosure

I declare the following conflict(s) of interest:

Conflict 1

• Nature of interest: [DESCRIBE THE INTEREST]
• Entity/relationship involved: [NAME OF PERSON OR COMPANY]
• Date interest arose: [DD/MM/YYYY]
• Value of interest (if applicable): [$ AMOUNT]

Conflict 2 (if applicable)

• Nature of interest: [DESCRIBE]
• Entity/relationship involved: [NAME]
• Date: [DD/MM/YYYY]
• Value: [$ AMOUNT]

Part C: No Conflict Declaration

[ ] I have NO conflicts of interest to declare at this time.

Part D: Management Plan

For each conflict declared above, describe how it will be managed:

• Management approach: [RECUSAL / RESTRICTION / TRANSFER / OTHER]
• Details: [DESCRIBE HOW THE CONFLICT WILL BE MANAGED]

Part E: Acknowledgement

I acknowledge that:

• I have read and understood the organisation's Conflict of Interest Policy
• I have disclosed all actual, potential, and perceived conflicts of interest
• I will notify the company secretary immediately if any new conflict arises
• I understand that failure to disclose may result in disciplinary action

Signature: _________________ Date: _________

For office use only:

• Register updated: [ ] Yes [ ] No
• Date entered: ________
• Reviewed by: ________