Declaration of Conflict of Interest - Template Form Pro · AU-law

CONFLICT OF INTEREST DECLARATION

________ (ACN ________) ("Organisation")

§1. PURPOSE

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1.2 In this declaration, a "conflict of interest" means any actual, potential or perceived interest, whether direct or indirect, financial or non-financial, that conflicts or may conflict with, or may reasonably be perceived to conflict with, the proper performance of the staff member's duties or the best interests of the Organisation.

§2. STAFF MEMBER DETAILS

Name: ________

Residential/postal address: ________

Job title/position: ________

Department/business unit: ________

Email: ________

Phone: ________

§3. DECLARATION

3.1 I, ________ of ________, hereby declare that, to the best of my knowledge and belief, the following statements are true and correct as at the date of signing, except as expressly disclosed in §4 of this form:

1. I do not have any actual, potential or perceived personal interest in any matter related to my role with ________ which could affect, or could reasonably be perceived to affect, my ability to act impartially and in the best interests of the Organisation.
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3. I do not hold any directorship, shareholding, office, employment, consultancy, gift, benefit or other financial or non-financial interest that could conflict, or could reasonably be perceived to conflict, with the proper performance of my duties for the Organisation.
4. I do not have any actual, potential or perceived personal interest in any matter related to my role which could be considered by a reasonable person to potentially affect my ability to act honestly and impartially, to fulfil my duties, and to perform my role in accordance with community standards, the Organisation's policies and applicable Australian law.

§4. DISCLOSURE OF CONFLICTS

4.1 Notwithstanding the statements in §3, I hereby disclose the following actual, potential or perceived conflict(s) of interest (including the nature of the interest, the parties involved, and any relevant value or amount). If no conflict exists, write "Nil":

________

4.2 Proposed steps to manage or mitigate the disclosed conflict(s) (if any):

________

§5. WARRANTIES AND ACKNOWLEDGEMENTS

I warrant, acknowledge and agree that:

1. I have carefully read and understood this form and the Organisation's Conflict of Interest Policy, and I confirm that the information I have provided is true, correct and complete to the best of my knowledge and belief.
2. I will immediately notify the Organisation in writing if there is any change in my circumstances which affects in any way the truth, correctness or completeness of the information provided in this form, or if any new actual, potential or perceived conflict of interest arises.
3. I understand that any failure to disclose an actual, potential or perceived conflict of interest, or the provision of any false, misleading or incomplete information in this form, may result in disciplinary action being taken against me, up to and including the termination of my employment or engagement with the Organisation, and may constitute a breach of my legal duties.
4. I understand that the Organisation may rely on the information provided in this form and may collect, use, store, retain and disclose this information for the purpose of identifying and managing conflicts of interest, in accordance with its policies, the Privacy Act 1988 (Cth) and the Australian Privacy Principles, and other applicable law.
5. I will take all reasonable steps to avoid, and to assist the Organisation in identifying and managing, any actual, potential or perceived conflict of interest disclosed in this form or arising in the future, including by withdrawing from any decision-making process in which I have a conflict where directed to do so.
6. This declaration does not limit any duty or obligation I owe to the Organisation under my contract of employment or engagement, the Organisation's policies, the general law or any applicable statute.

§6. EXECUTION

Signed by the staff member:

Signature: ............................................................

Name: ________

Date: ________

Received and reviewed on behalf of the Organisation:

Signature: ............................................................

Name: ________

Position: ________

Date: ________