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Declaration of Conflict of Interest - Template Form

✓ Valid in Australia

Create your Declaration of Conflict of Interest - Template Form for use in Australia. Answer a few plain-English questions and the document fills in automatically as you go — then download it in Word and PDF, ready to sign or share.

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Declaration of Conflict of Interest - Template Form
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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.
  • I will take all reasonable steps to avoid, and to assist the Organisation in managing, any actual, potential or perceived conflict of interest disclosed in this form or arising in the future.


Signed by ________: ............................................................

Date: ________

Fields you complete are inserted into the document live. This template is general guidance only — not legal advice.